CMS 1500 ICD 10 WYOMING Manual CMS1500 4 1 17
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DIVISION OF HEALTHCARE FINANCING CMS 1500 ICD-10 April 1, 2017 General Information____________________________________________________________ Overview Thank you for your willingness to serve clients of the Medicaid Program and other medical assistance programs administered by the Division of Healthcare Financing. This manual supersedes all prior versions. Rule References Providers must be familiar with all current rules and regulations governing the Medicaid Program. Provider manuals are to assist providers with billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are only a reference tool. They are not a summary of the entire rule. In the event that the manual conflicts with a rule, the rule prevails. Wyoming State Rules may be located at, http://soswy.state.wy.us/Rules/default.aspx. CMS 1500 ii Revision 4/1/17 General Information____________________________________________________________ Importance of Fee Schedules and Provider’s Responsibility Procedure codes listed in the following Sections are subject to change at any time without prior notice. The most accurate way to verify coverage for a specific service is to review the Medicaid fee schedules on the website (2.1, Quick Reference). Fee schedules list Medicaid covered codes, provide clarification of indicators, such as whether a code requires prior authorization and the number of days in which followup procedures are included. Not all codes are covered by Medicaid or are allowed for all taxonomy codes (provider types). It is the provider’s responsibility to verify this information. Use the current fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT-4 and HCPCS Level II coding books. Remember to use the fee schedule and coding books that pertain to the appropriate dates of service. Wyoming Medicaid is required to comply with the coding restrictions under the National Correct Coding Initiative (NCCI) and providers should be familiar with the NCCI billing guidelines. NCCI information may be reviewed at http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html. Getting Questions Answered The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific department such as Provider Relations or Medical Policy (2.1, Quick Reference). Medicaid manuals, bulletins, fee schedules, forms, and other resources are available on the Medicaid website or by contacting Provider Relations. CMS 1500 iii Revision 4/1/17 General Information____________________________________________________________ AUTHORITY The Wyoming Department of Health is the single state agency appointed as required in the Code of Federal Regulations (CFR) to comply with the Social Security Act to administer the Medicaid Program in Wyoming. The Division of Healthcare Financing (DHCF) directly administers the Medicaid Program in accordance with the Social Security Act, the Wyoming Medical Assistance and Services Act, (W.S. 42-4-101 et seq.), and the Wyoming Administrative Procedure Act (W.S. 16-3-101 et seq.). Medicaid is the name chosen by the Wyoming Department of Health for its Medicaid Program. This manual is intended to be a guide for providers when filing medical claims with Medicaid. The manual is to be read and interpreted in conjunction with Federal regulations, State statutes, administrative procedures, and Federally approved State Plan and approved amendments. This manual does not take precedence over Federal regulation, State statutes or administrative procedures. CMS 1500 iv Revision 4/1/17 General Provider Information____________________________________________________ Contents: Contents: v Chapter One – General Information ..........................................................................1 Chapter Two – Getting Help When You Need It ......................................................6 Chapter Three – Provider Responsibilities ..............................................................15 Chapter Four – Utilization Review ..........................................................................32 Chapter Five – Client Eligibility ..............................................................................39 Chapter Six – Common Billing Information ...........................................................46 Chapter Seven – Third Party Liability ...................................................................112 Chapter Eight – Electronic Data Interchange (EDI) ..............................................124 Chapter Nine – Wyoming HIPAA 5010 Electronic Specifications ......................132 Chapter Ten – Important Information ....................................................................154 Chapter Eleven – Covered Services – Ambulance ................................................158 Chapter Twelve – Covered Services – Audiology.................................................166 Chapter Thirteen – Covered Services – Behavioral Health ...................................170 Chapter Fourteen – Covered Services – Children’s Mental Health Waiver .........207 Chapter Fifteen – Covered Services – Chiropractic Services ................................210 Chapter Sixteen – Covered Services – Developmental Centers ............................214 Chapter Seventeen – Covered Services – Dietician ..............................................221 Chapter Eighteen – Covered Services – DME Billing ..........................................224 Chapter Nineteen – Covered Services – Family Planning.....................................228 Chapter Twenty – Covered Services – Health Check ...........................................230 Chapter Twenty One – Covered Services – Interpreter Services ..........................245 Chapter Twenty Two – Covered Services – Laboratory Services.........................248 Chapter Twenty Three – Covered Services – Non-Emergency Medical Transportation ........................................................................................................253 CMS 1500 v Revision 4/1/17 General Provider Information____________________________________________________ Chapter Twenty Four – Covered Services – Practitioner Services .......................257 Chapter Twenty Five – Covered Services – Pregnant by Choice..........................334 Chapter Twenty Six – Covered Services – Therapy Services ...............................339 Appendix CMS 1500 346 vi Revision 4/1/17 General Provider Information____________________________________________________ Chapter One – General Information 1.1 How the CMS-1500 Manual is Organized ............................................................ 1 1.2 Updating the Manual ............................................................................................. 2 1.2.1 RA Banner Notices/Samples ................................................................................. 3 1.2.2 Medicaid Bulletin Notification/Sample................................................................. 4 1.2.3 Wyoming Department of Health (WDH) State Letter/Sample ............................. 4 1.3 State Agency Responsibilities ............................................................................... 5 1.4 Fiscal Agent Responsibilities ................................................................................ 5 Ch. 1 Index 1 Revision 4/1/17 General Provider Information____________________________________________________ 1.1 How the CMS-1500 Manual is Organized The table below provides a quick reference describing how the CMS-1500 Manual is organized. Chapter Description Two Getting Help When You Need It – Quick Reference guide, telephone numbers and addresses and web sites for help and training. Three Provider Responsibilities – Obligations and rights as a Medicaid provider. The topics covered include enrollment changes, civil rights, group practices, provider-patient relationship, and record keeping requirements. Four Utilization Review – Fraud and abuse definitions, the review process, and rights and responsibilities. Five Client Eligibility – How to verify eligibility when a client presents their Medicaid card. Six Common Billing Information – Basic claim information, completing the claim form, cap limits, co-pays, prior authorizations, timely filing, consent forms, NDC, working the Medicaid remittance advice (RA) and completing adjustments. Seven Third Party Liability (TPL)/Medicare – Explains what TPL/Medicare is, how to bill it and exceptions to it. Eight Electronic Data Interchange (EDI) – Explains the advantages of exchanging documents electronically. Secured Provider Web Portal registration process. Nine Wyoming Specific HIPAA 5010 Electronic Specifications – This chapter covers the Wyoming Specific requirements pertaining to electronic billing. Wyoming payor number and electronic adjustments/voids. Ten CMS-1500 Covered Services – This chapter is alphabetical by professional service and provides information such as: definitions, procedure code ranges, documentation requirements, covered and noncovered services and billing examples. Appendices Appendices – Provide key information in an at-a-glance format. This includes the Provider Manual Version Control Table, and last quarters Provider Notifications. Ch. 1 Index 1 Revision 4/1/17 General Provider Information____________________________________________________ 1.2 Updating the Manual When there is a change in the Medicaid Program, Medicaid will update the manuals on a quarterly (January, April, July, and October) basis and publish them to the Medicaid website. Most of the changes come in the form of provider bulletins (via email) and Remittance Advice (RA) banners, although others may be newsletters or Wyoming Department of Health letters (via email) from state officials. The updated provider manuals will be posted to the website and will include all updates from the previous quarter. It is in the provider’s best interest to download an updated provider manual and keep their email addresses up-to-date. Bulletin, RA banner, newsletter and state letter information will be posted to the website as it is sent to providers, and will be incorporated into the provider manuals as appropriate to ensure the provider has access to the most up to date information regarding Medicaid policies and procedures. RA banner notices appear on the first page of the proprietary Wyoming Medicaid Remittance Advice (RA), which is available for download through the Secured Provider Web Portal after each payment cycle in which the provider has claims processed or “in process”. This same notice also appears on the RA payment summary email that is sent out each week after payment, and is published to the “What’s New” section of the website. It is critical for providers to keep their contact email address(es) up-to-date to ensure they receive all notices published by Wyoming Medicaid. It is recommended that providers add the “wycustomersvcs@acs-inc.com” email address from which notices are sent to their address books to avoid these emails being inadvertently sent to junk or spam folders. All bulletins and updates are published to the Medicaid website (2.1, Quick Reference). NOTE: Ch. 1 Index Provider bulletins and state letter email notifications are sent to the email addresses on-file with Medicaid and are sent in two (2) formats, plain text and HTML. If the HTML format is received or accepted then the plain text format is not sent. 2 Revision 4/1/17 General Provider Information____________________________________________________ 1.2.1 RA Banner Notices/Samples RA banners are limited in space and formatting options and are used to notify providers quickly and often refer providers elsewhere for additional information. Sample RA Banner: ************************************************************************ ICD-10 IMPLEMENTATION OCTOBER 1, 2015 EXPECT: 1) LONGER WAIT TIMES WHEN CALLING PROVIDER RELATIONS OR EDI SERVICES 2) INCREASED POSSIBILITY OF RECEIVING A BUSY DISCONNECT WHEN EXITING THE IVR 3) DO NOT EXPECT THE AGENTS TO PROVIDE ICD-10 CODES TROUBLESHOOTING TIPS PRIOR TO CALLING THE CALL CENTERS: 1) IF YOUR SOFTWARE OR VENDOR/CLEARINGHOUSE IS NOT ICD-10 READY--FREE SOFTWARE AVAILABLE ON THE WY MEDICAID WEBSITE (CANNOT DROP TO PAPER) 2) ICD-10 DX/SURGICAL DENIALS, VERIFY FIRST: CODES ARE BOTH ALPHA & NUMERIC, DX QUALIFIER, O VS 0, 1 VS I 3) VERIFY DOS, PRIOR TO 10/1/15 BILL WITH ICD-9 AND ON OR AFTER 10/1/15 BILL WITH ICD-10 CODES 4) INPATIENT SERVICES THAT SPAN 9/2015-10/2015 BILL WITH ICD-10 HTTP://WYMEDICAID. ACS-INC.COM/PROVIDER_HOME.HTML ************************************************************************** Sample RA Payment Summary (weekly email notification): -----Original Message----- From: Wyoming Medicaid [mailto:wycustomersvc@xerox.com] Sent: Thursday, May 28, 2015 5:17 AM To: Provider Email Name Subject: Remittance Advice Payment Summary On 05/27/2015, at 05:16, Wyoming Medicaid wrote: Dear Provider Name, The following is a summary of your Wyoming Medicaid remittance advice 123456 for 05/27/2015, an RA Banner with important information may follow. ***************************************************** RA PAYMENT SUMMARY ***************************************************** To: Provider Name NPI Number: 1234567890 Provider ID: 111111111 Remittance Advice Number: 123456 Amount of Check: 16,070.85 The RA banner notification will appear here when activated for the provider’s taxonomy (provider type) Ch. 1 Index 3 Revision 4/1/17 General Provider Information____________________________________________________ 1.2.2 Medicaid Bulletin Notification/Sample Medicaid bulletin email notifications typically announce billing changes, new codes requiring prior authorization, reminders, up and coming initiatives, etc. Sample bulletin email notification (HTML format): 1.2.3 Wyoming Department of Health (WDH) State Letter/Sample WDH email notifications typically announce significant Medicaid policy changes, RAC and other audits, etc. Sample WDH email notification (HTML format): Ch. 1 Index 4 Revision 4/1/17 General Provider Information____________________________________________________ 1.3 State Agency Responsibilities The Division of Healthcare Financing administers the Medicaid Program for the Department of Health. They are responsible for financial management, developing policy, establishing benefit limitations, payment methodologies and fees, and performing utilization review. 1.4 Fiscal Agent Responsibilities Conduent is the fiscal agent for Medicaid. They process all claims and adjustments, with the exception of pharmacy. They also answer provider inquiries regarding claim status, payments, client eligibility, known third party insurance information and provider training visits to train and assist the provider office staff on Medicaid billing procedures or to resolve claims payment issues. NOTE: Ch. 1 Index Wyoming Medicaid is not responsible for the training of the provider’s billing staff or to provide procedure or diagnosis codes or coding training. 5 Revision 4/1/17 Getting Help When You Need It__________________________________________________ Chapter Two – Getting Help When You Need It 2.1 Quick Reference .................................................................................................... 7 2.2 How to Call for Help ........................................................................................... 11 2.3 How to Write for Help......................................................................................... 11 2.3.1 Provider Inquiry Form ......................................................................................... 12 2.4 How to Get a Provider Training Visit ................................................................. 12 2.5 How to Get Help Online ...................................................................................... 13 2.6 Training Seminars/Presentations ......................................................................... 13 Ch.2 Index 6 Revision 4/1/17 Getting Help When You Need It__________________________________________________ 2.1 Quick Reference Agency Name & Address Telephone/Fax Numbers Web Address Contact For: Dental Services – Interactive Voice Response (IVR) System Tel (800)251-1270 24 / 7 N/A Payment inquiries Client eligibility Medicaid client number and information Lock-in status Cap limits Medicare Buy-In data Service limitations Client third party coverage information NOTE: The client’s Medicaid ID number or social security number is required to verify client eligibility. Claims PO Box 547 Cheyenne, WY 82003-0547 Dental Service PO Box 667 Cheyenne, WY 82003-0667 EDI Services PO Box 667 Cheyenne, WY 82003-0667 N/A N/A Tel (888)863-5806 9-5pm MST M-F http://wymedicaid.acsinc.com/ Fax (307)772-8405 Tel (800)672-4959 OPTION 3 9-5pm MST M-F http://wymedicaid.acsinc.com/ Ch.2 Index N/A Claim adjustment submissions Hardcopy claims submissions Returning Medicaid checks Bulletin/manual inquiries Claim inquiries Claim submission problems Client eligibility How to complete forms Payment inquiries Request Field Representative visit Training seminar questions Timely filing inquiries Verifying validity of procedure codes Claim void/adjustment inquiries WINASAP training Web Portal training EDI Enrollment Forms Trading Partner Agreement WINASAP software Technical support for WINASAP Technical support for vendors, billing agents and clearing houses Web Portal registration/password resets Technical support for Web Portal Download WINASAP software Fax (307)772-8405 ACS EDI Gateway http://www.acs-gcro.com 7 Revision 4/1/17 Getting Help When You Need It__________________________________________________ Agency Name & Address Medical Policy PO Box 667 Cheyenne, WY 82003-0667 Telephone/Fax Numbers Tel (800)251-1268 OPTIONS 1,1,4,3 9-5pm MST M-F (24/7 Voicemail Available) Web Address http://wymedicaid.acsinc.com/manuals.html Fax (307)772-8405 Provider Relations PO Box 667 Cheyenne, WY 82003-0667 Tel (800)251-1268 http://wymedicaid.acsinc.com/ 9-5pm MST M-F (call center hours) Fax (307)772-8405 (IVR Navigation Tips available on the website) 24 / 7 (IVR availability) http://wymedicaid.acsinc.com/contact.html Contact For: Cap limit waiver requests Prior authorization requests for: Out-of-State Home Health Surgeries requiring prior authorization Hospice Services: Limited to clients residing in a nursing home Provider enrollment questions Bulletin/Manuals inquiries Cap limits Claim inquiries Claim submission problems Client eligibility Claim void/adjustment inquiries Form completion Payment inquiries Request Field Representative visit Training seminar questions Timely filing inquiries Troubleshooting prior authorization problems Verifying validity of procedure codes Tel (800)251-1268 OPTION 2 9-5pm MST M-F Fax (307)772-8405 Select Option 2 if you need Medicare or estate and trust recovery assistance THEN Third Party Liability (TPL) PO Box 667 Cheyenne, WY 82003-0667 Select Option 2 if you are with an insurance company, attorney’s office or child support enforcement N/A OR Select Option 3 for Medicare and Medicare Premium payments Client accident covered by liability or casualty insurance or legal liability is being pursued Estate and Trust Recovery Medicare Buy-In status Reporting client TPL New insurance coverage Policy no longer active Problems getting insurance information needed to bill Questions or problems regarding third party coverage or payers WHIPP program OR Select Option 4 for estate and trust recovery inquires Ch.2 Index 8 Revision 4/1/17 Getting Help When You Need It__________________________________________________ Agency Name & Address Transportation Services PO Box 667 Cheyenne, WY 82003-0667 Telephone/Fax Numbers Tel (800)595-0011 Web Address Contact For: http://wymedicaid.acsinc.com/client/ Client inquiries: Prior authorize transportation arrangements Request travel assistance Verify transportation is reimbursable 9-5pm MST M-F (24/7 Voicemail Available) Fax (307)772-8405 Qualis Health DMEPOS PO Box 33400 Seattle, WA 98133 WYhealth (Utilization and Care Management) PO Box 49 Cheyenne, WY 82003-0049 Aids Drug Assistance Program (ADAP) Maternal & Child Health (MCH) /Children Special Health (CSH) 6101 N. Yellowstone Rd. Ste. 420 Cheyenne, WY 82002 Severe Malocclusion Social Security Administration (SSA) Medicare Ch.2 Index Tel (800)783-8606 8a-6pm MST M-F http://www.qualishealth.org/ Fax (877)810-9265 Tel (888)545-1710 Nurse Line: (OPTION 2) http://www.WYhealth.net/ Fax PASRRs Only (888)245-1928 (Attn: PASRR Processing Specialist) Tel (307)777-5800 Prior authorization for: Acute Psych Extended Psych Extraordinary heavy care Gastric Bypass Inpatient rehabilitation Psychiatric Residential Treatment Facility (PRTF) Transplants Vagus Nerve Stimulator N/A 1) Prescription medications 2) Program information N/A High Risk Maternal Newborn intensive care Program information Severe Malocclusion Applications and Criteria Fax (307)777-7382 Tel (307)777-7941 Tel (800)438-5795 DMEPOS Covered Services manual Prior authorization request for Durable Medical Equipment (DME) or Prosthetic/Orthotic Services (POS) Questions related to documentation or clinical criteria for DMEPOS Medicaid Incentive Programs Diabetes Incentive Program ER Utilization Program P4P SBIRT Educational Information about WYhealth Programs Fax (307)777-7215 Tel (307)777-8088 Fax (307)777-6964 N/A Tel (800)772-1213 N/A Social Security benefits Tel (800)633-4227 N/A Medicare information 9 Revision 4/1/17 Getting Help When You Need It__________________________________________________ Agency Name & Address Division of Healthcare Financing (DHCF) 6101 Yellowstone Rd. Ste. 210 Cheyenne, WY 82002 DHCF Program Integrity 6101 Yellowstone Rd. Ste. 210 Cheyenne, WY 82002 Telephone/Fax Numbers Tel (307)777-7531 Tel (866)571-0944 Web Address http://www.health.wyo.gov /healthcarefin/index.html Contact For: Fax (307)777-6964 Client or Provider Fraud, Waste and Abuse Tel (855)846-2563 N/A NOTE: Callers may remain anonymous when reporting Stop Medicaid Fraud Medicaid State Rules State Policy and Procedures Concerns/Issues with state Contractors/Vendors Tel (855)846-2563 http://stopmedicaidfraud.w yo.gov Information and education regarding fraud, waste, and abuse in the Wyoming Medicaid program To report fraud, waste and abuse DHCF Pharmacy Program 6101 Yellowstone Rd. Ste. 210 Cheyenne, WY 82002 Goold Health Systems, Inc. (GHS) PBM Vendor Customer Service Center (CSC) , Wyoming Department of Health 2232 Dell Range Blvd, Suite 300 Cheyenne, WY 82009 Tel (307)777-7531 N/A General questions Fax (307)777-6964 Tel (877)209-1264 (Pharmacy Help Desk) Tel (877)207-1126 (PA Help Desk) Tel (855)294-2127 TTY/TDD (855)29-5205 (Clients Only, CSC cannot speak to providers) http://www.wymedicaid.org/ Pharmacy prior authorization Enrollment Pharmacy manuals FAQs www.wesystem.wyo.gov Client Medicaid applications Eligibility questions regarding: 1) Family and Children’s programs 2) Tuberculosis Assistance Program 3) Medicare Savings Programs 4) Employed Individuals with Disabilities 7-6pm MST M-F Fax (855)329-5205 Wyoming Department of Health Long Term Care Unit (LTC) Ch.2 Index Tel (855)203-2936 8-5pm MST M-F N/A Fax (307)777-8399 10 Nursing home program eligibility questions Patient Contribution Waiver Programs Inpatient Hospital Hospice Home Health Revision 4/1/17 Getting Help When You Need It__________________________________________________ Agency Name & Address Telephone/Fax Numbers Web Address Contact For: Wyoming Medicaid N/A Tel (888) 545-1710 HealthHelp http://wymedicaid.acsinc.com https://wyhealth.net Option 2 2.2 Provider manuals HIPAA electronic transaction data exchange Fee schedules On-line Provider Enrollment Frequently asked questions (FAQs) Forms (e.g., Claim Adjustment/Void Request Form) Contacts What’s new Remittance Advice Retrieval EDI enrollment form Trading Partner Agreement Secured Provider Web Portal Training Tutorials PA’s for Radiology, Cardiology and Radiation Oncology How to Call for Help The fiscal agent maintains a well-trained call center that is dedicated to assisting providers. These individuals are prepared to answer inquiries regarding client eligibility, service limitations, third party coverage, electronic transaction questions and provider payment issues. 2.3 How to Write for Help In many cases, writing for help provides the provider with more detailed information about the provider claims or clients. In addition, written responses may be kept as permanent records. Reasons to write vs. calling: Appeals – Include claim, all documentation previously submitted with the claim, explanation for request, documentation supporting the request. Written documentation of answers – Include all documentation to support the provider request. Rate change requests – Include request and any documentation supporting the provider request. Requesting a service to be covered by Wyoming Medicaid – Include request and any documentation supporting the provider request. To expedite the handling of written inquiries, we recommend providers use a Provider Inquiry Form (2.3.1, Provider Inquiry Form). Providers may copy the form Ch.2 Index 11 Revision 4/1/17 Getting Help When You Need It__________________________________________________ in this manual. Provider Relations will respond to the provider inquiry within ten business days of receipt. 2.3.1 Provider Inquiry Form NOTE: 2.4 Click image above to be taken to a printable version of this form. How to Get a Provider Training Visit Provider Relations Field Representatives are available to train or address questions the provider’s office staff may have on Medicaid billing procedures or to resolve claims payment issues. Provider Relations Field Representatives are available to assist providers with help in their location, by phone, or webinar with Wyoming Medicaid billing questions and issues. Generally, to assist a provider with claims specific questions, it is best for the Field Representative to communicate via phone or webinar as they will then have access to the systems and tools needed to review claims and policy information. Provider Training visits may be conducted when larger groups are interested in training related to Wyoming Medicaid billing. When conducted with an individual provider’s office, a Provider Training visit generally consists of a review of a provider’s claims statistics, including top reasons for denials and denial rates, and a review of important Medicaid training and resource information. Provider Training Workshops may be held during the summer months to review this information in a larger group format. Ch.2 Index 12 Revision 4/1/17 Getting Help When You Need It__________________________________________________ Due to the rural and frontier nature, and weather in Wyoming, visits are generally conducted during the warmer months only. For immediate assistance, a provider should always contact Provider Relations (2.1, Quick Reference). 2.5 How to Get Help Online The address for Medicaid’s public website is http://wymedicaid.acs-inc.com. This site connects Wyoming’s provider community to a variety of information including: Answers to the providers frequently asked Medicaid questions. Claim, prior authorization, and other forms for download. Free download of latest WINASAP software and latest WINASAP updates. Free download of WINASAP Training Manuals and Tutorials. Medicaid publications, such as provider handbooks and bulletins. Payment Schedule. Primary resource for all information related to Medicaid. Wyoming Medicaid Secured Provider Web Portal. Wyoming Medicaid Secured Provider Web Portal tutorials. The Medicaid public website also links providers to Medicaid’s Secured Provider Web Portal, which delivers the following services: 278 Electronic Prior Authorization Requests – Ability to submit and 2.6 retrieve prior authorization requests and responses electronically via the web. Data Exchange – Upload and download of electronic HIPAA transaction files. Remittance Advice Reports – Retrieve recent Remittance Advices o Wyoming Medicaid proprietary RA 835 User Administration – Add, edit, and delete users within the provider’s organization who can access the Secured Provider Web Portal. 837 Electronic Claim Entry – Interactively enter dental, institutional and medical claims without buying expensive software. PASRR entry LT101 Look-Up Training Seminars/Presentations The fiscal agent and the Division of Healthcare Financing may sponsor periodic training seminars at selected in-state and out-of-state locations. Providers will receive advance notice of seminars by Medicaid bulletin email notifications, provider Ch.2 Index 13 Revision 4/1/17 Getting Help When You Need It__________________________________________________ bulletins (hard copies) or Remittance Advice (RA) banners. Providers may also check the Medicaid website for any recent seminar information. Ch.2 Index 14 Revision 4/1/17 Provider Responsibilities________________________________________________________ Chapter Three – Provider Responsibilities 3.1 Enrollment/Re-Enrollment .................................................................................. 16 3.1.1 Notifying Medicaid of Updated Provider Information........................................ 18 3.1.2 Re-Certification ................................................................................................... 19 3.1.3 Discontinuing Participation in the Medicaid Program ........................................ 19 3.2 Accepting Medicaid Clients ................................................................................ 19 3.2.1 Compliance Requirements .................................................................................. 19 3.2.2 Provider-Patient Relationship.............................................................................. 19 3.2.2.1 Medicare/Medicaid Dual Eligible Clients ....................................................... 21 3.2.2.2 Accepting a Client as Medicaid After Billing the Client................................. 22 3.2.2.3 Mutual Agreements Between the Provider & Client ....................................... 22 3.2.3 Missed Appointments .......................................................................................... 22 3.3 Medicare Covered Services ................................................................................. 23 3.4 Medical Necessity ............................................................................................... 23 3.5 Medicaid Payment is Payment in Full ................................................................. 24 3.6 Medicaid ID Card ................................................................................................ 25 3.7 Verification of Client Age ................................................................................... 25 3.8 Verification Options ............................................................................................ 25 3.8.1 Free Services ....................................................................................................... 25 3.8.2 Fee for Service..................................................................................................... 26 3.9 Freedom of Choice .............................................................................................. 26 3.10 Out-of-State Service Limitations......................................................................... 26 3.11 Record Keeping, Retention and Access .............................................................. 27 3.11.1 Requirements ....................................................................................................... 27 3.11.2 Retention of Records ........................................................................................... 28 3.11.3 Access to Records ............................................................................................... 28 3.11.4 Audits .................................................................................................................. 28 3.12 Ch. 3 Index Tamper Resistant RX Pads .................................................................................. 30 15 Revision 4/1/17 Provider Responsibilities________________________________________________________ 3.1 Enrollment/Re-Enrollment Medicaid payment is made only to providers who are actively enrolled in the Medicaid Program. Providers are required to complete an enrollment application, undergo a screening process and sign a Provider Agreement at least every five (5) years. In addition, certain provider types are required to pay an application fee, submit proof of licensure and/or certification. These requirements apply to both instate and out-of-state providers. All providers have been assigned one (1) of three (3) categorical risk levels under the Affordable Care Act (ACA) and are required to be screened as follows: Categorical Risk Level LIMITED Includes: Physician and nonphysican practitioners, (includes nurse practitioners, CRNAs, occupational therapists, speech/language pathologist audiologists) and medical groups or clinics Ambulatory surgical centers Competitive Acquisition Program/Part B Vendors: End-stage renal disease facilities Federally qualified health centers (FQHC) Histocompatibility laboratories Hospitals, including critical access hospitals, VA hospitals, and other federally-owned hospital facilities Health programs operated by an Indian Health program Mammography screening centers Mass immunization roster billers Organ procurement organizations Pharmacy newly enrolling or revalidating via the CMS-855B application Radiation therapy centers Religious non-medical health care institutions Rural health clinics Skilled nursing facilities MODERATE Includes: Ambulance service suppliers Community mental health centers (CMHC) Comprehensive outpatient rehabilitation facilities (CORF) Hospice organizations Independent diagnostic testing facilities Physical therapists enrolling as individuals or as group practices Portable x-ray suppliers Revalidating home health agencies Revalidating DMEPOS suppliers Ch. 3 Index Screening Requirements Verifies provider or supplier meets all applicable Federal regulations and State requirements for the provider or supplier type prior to making an enrollment determination Conducts license verifications, including licensure verification across State lines for physicians or non-physician practitioners and providers and suppliers that obtain or maintain Medicare billing privileges as a result of State licensure, including State licensure in States other than where the provider or supplier is enrolling Conducts database checks on a pre- and post-enrollment basis to ensure that providers and suppliers continue to meet the enrollment criteria for their provider/supplier type. Performs the “limited” screening requirements listed above Conducts an on-site visit 16 Revision 4/1/17 Provider Responsibilities________________________________________________________ Categorical Risk Level HIGH Includes: Prospective (newly enrolling) home health agencies Prospective (newly enrolling) DMEPOS suppliers Prosthetic/orthotic (newly enrolling) suppliers Individual practitioners suspected of identity theft, placed on previous payment suspension, previously excluded by the OIG, and/or previously had billing privileges denied or revoked within the last ten (10) years Screening Requirements Performs the “limited” and “moderate” screening requirements listed above. Requires the submission of a set of fingerprints for a national background check from all individuals who maintain a five (5) percent or greater direct or indirect ownership interest in the provider or supplier. Conducts a fingerprint-based criminal history record check of the FBI’s Integrated Automated Fingerprint Identification System on all individuals who maintain a five (5 percent or greater direct or indirect ownership interest in the provider or supplier Categorical Risk Adjustment: CMS adjusts the screening level from limited or moderate to high if any of the following occur: Exclusion from Medicare by the OIG Had billing privileges revoked by a Medicare contractor within the previous ten (10) years and is attempting to establish additional Medicare billing privilege by— o Enrolling as a new provider or supplier o Billing privileges for a new practice location Has been terminated or is otherwise precluded from billing Medicaid Has been excluded from any Federal health care program Has been subject to a final adverse action as defined in §424.502 within the previous ten (10) years The ACA has imposed an application fee on the following institutional providers: In-state only o o o o o o Institutional Providers PRTFs Substance abuse centers (SAC) Wyoming Medicaid-only nursing facilities Community Mental Health Centers (CMHC) Wyoming Medicaid-only home health agencies (both newly enrolling and re-enrolling) Providers that are enrolled in Medicare, Medicaid in other states, and CHIP are only required to pay one (1) enrollment fee. Verification of this payment must be included with the enrollment application. The application fee is required for: Ch. 3 Index New enrollments Enrollments for new locations Re-enrollments Medicaid requested re-enrollments (as a result of inactive enrollment statuses) 17 Revision 4/1/17 Provider Responsibilities________________________________________________________ The application fee is non-refundable and is adjusted annually based on the Consumer Price Index (CPI) for all urban consumers. After a providers enrollment application has been approved, a welcome letter will be sent. If an application is not approved, a notice including the reasons for the decision will be sent to the provider. No medical provider is declared ineligible to participate in the Medicaid Program without prior notice. To enroll as a Medicaid provider, all providers must complete the on-line enrollment application available on the Medicaid website (2.1, Quick Reference). 3.1.1 Notifying Medicaid of Updated Provider Information If any information listed on the original enrollment application subsequently changes, providers must notify Medicaid in writing 30-days prior to the effective date of the change. Changes that would require notifying Medicaid include, but are not limited to, the following: Current licensing information Facility or name changes New ownership information New telephone or fax numbers Physical, correspondence or payment address change New email addresses Tax Identification Number It is critical that providers maintain accurate contact information, including email addresses, for the distribution of notifications to providers. Wyoming Medicaid policy updates and changes are distributed by email, and occasionally by postal mail. Providers are obligated to read, know and follow all policy changes. Individuals who receive notifications on behalf of an enrolled provider are responsible for ensuring they are distributed to the appropriate personnel in the organization, office, billing office, etc. Effective September 1, 2016, if any of the above contact information is found to be inaccurate (mail is returned, emails bounce, phone calls are unable to be placed or physical site verification fails, etc.) the provider will be placed on a claims hold. Claims will be held for 30 days pending an update of the information. A letter will be sent to the provider, unless both the physical and correspondence addresses have had mail returned, notifying them of the hold and describing options to update contact information. If the information is updated within the 30 days, the claim will be released to complete normal processing; if a claim is held for this reason for more than 30 days, it will then be denied and the provider will have to resubmit once the incorrect information is updated. The letter will document the information currently on file with Wyoming Medicaid and allow you to make updates/changes as needed. Ch. 3 Index 18 Revision 4/1/17 Provider Responsibilities________________________________________________________ 3.1.2 Re-Certification Sixty (60) days prior to licensure/certification expiration Medicaid sends all providers a letter requesting a copy of their license or other certifications. If these documents are not submitted within 60-days of their expiration date, the provider will be terminated as a Medicaid provider. 3.1.3 Discontinuing Participation in the Medicaid Program The provider may discontinue participation in the Medicaid Program at any time. Thirty (30) days written notice of voluntary termination is requested. Notices should be addressed to Provider Relations, attention Enrollment Services (2.1, Quick Reference). 3.2 Accepting Medicaid Clients 3.2.1 Compliance Requirements All providers of care and suppliers of services participating in the Medicaid Program must comply with the requirements of Title VI of the Civil Rights Act of 1964, which requires that services be furnished to clients without regard to race, color, or national origin. Section 504 of the Rehabilitation Act provides that no individual with a disability shall, solely by reason of the handicap: Be excluded from participation; Be denied the benefits; or Be subjected to discrimination under any program or activity receiving federal assistance. Each Medicaid provider, as a condition of participation, is responsible for making provision for such individuals with a disability in their program activities. As an agent of the Federal government in the distribution of funds, the Division of Healthcare Financing is responsible for monitoring the compliance of individual providers and, in the event a discrimination complaint is lodged, is required to provide the Office of Civil Rights (OCR) with any evidence regarding compliance with these requirements. 3.2.2 Provider-Patient Relationship The relationship established between the client and the provider is both a medical and a financial one. If a client presents himself/herself as a Medicaid client, the provider must determine whether the provider is willing to accept the client as a Medicaid patient before treatment is rendered. Ch. 3 Index 19 Revision 4/1/17 Provider Responsibilities________________________________________________________ Providers must verify eligibility each month as programs and plans are redetermined on a varying basis, and a client eligible one (1) month may not necessarily be eligible the next month. NOTE: Presumptive Eligibility may begin or end mid-month. It is the provider’s responsibility to determine all sources of coverage for any client. If the client is insured, by an entity other than Medicaid and Medicaid is unaware of the insurance, the provider must submit a Third Party Resources Information Sheet (7.7.1, Third Party Resources Information Sheet) to Medicaid. The provider may not discriminate based on whether or not a client is insured. Providers may not discriminate against Wyoming Medicaid clients. Providers must treat Wyoming Medicaid clients the same as any other patient in their practice. Policies must be posted or supplied in writing and enforced with all patients regardless of payment source. When and what may be billed to a Medicaid client. Once this agreement has been reached, all Wyoming Medicaid covered services the provider renders to an eligible client are billed to Medicaid. Client is Covered by a FULL COVERAGE Medicaid Program and the provider accepts the client as a Medicaid client Client is Covered by a LIMITED COVERAGE Medicaid Program and the provider accepts the client as a Medicaid client FULL COVERAGE or LIMITED COVERAGE Medicaid Program and the provider does not accept the client as a Medicaid client Client is not covered by Medicaid (not a Medicaid client) Service is covered by Medicaid Provider can bill the client only for any applicable copay Provider can bill the client if the category of service is not covered by the client’s limited plan Provider can bill the client if written notification has been Provider may bill client Service is covered by Medicaid, but client has exceeded his/her service limitations (cap limits) Provider can bill the client OR provider Can request cap limit waiver and bill Medicaid Provider can bill the client OR provider can request cap limit waiver and bill Medicaid Provider can bill the client if written notification has been given to the client that they are not being accepted as a Medicaid client Provider can bill client Ch. 3 Index 20 Revision 4/1/17 Provider Responsibilities________________________________________________________ Service is not covered by Medicaid Client is Covered by a FULL COVERAGE Medicaid Program and the provider accepts the client as a Medicaid client Client is Covered by a LIMITED COVERAGE Medicaid Program and the provider accepts the client as a Medicaid client FULL COVERAGE or LIMITED COVERAGE Medicaid Program and the provider does not accept the client as a Medicaid client Provider can bill the client only if a specific financial agreement has been made in writing Provider can bill the client if the Category of service is not covered by the client’s limited plan. If the Category of service is covered, the provider can only bill the client if a specific financial agreement has been made in writing Provider can bill the client if written notification has been given to the client that they are not being accepted as a Medicaid client Client is not covered by Medicaid (not a Medicaid client) Provider can bill client Full Coverage Plan – Plan covers the full range of medical, dental, hospital, and pharmacy services and may cover additional nursing home or waiver services. Limited Coverage Plan – Plan with services limited to a specific category or type of coverage. Specific Financial Agreement – specific written agreement between a provider and a client, outlining the specific services and financial charges for a specific date of service, with the client agreeing to the financial responsibility for the charges. 3.2.2.1 Medicare/Medicaid Dual Eligible Clients Dual eligible clients are those clients who have both Medicare and Medicaid. For clients on the QMB plan, CMS guidelines indicate that coinsurance and deductible amounts remaining after Medicare pays cannot be billed to the client under any circumstances, regardless of whether you bill Medicaid or not. For clients on other plans who are dual eligible, coinsurance and deductible amounts remaining after Medicare payment cannot be billed to the client if the claim was billed to Wyoming Medicaid, regardless of payment amount (including claims that Medicaid pays at $0). If the claim is not billed to Wyoming Medicaid, and the provider agrees in writing prior to providing the service not to accept the client as a Medicaid client and advises the client of his or her financial responsibility, and the client is not on a QMB plan, then the client can be billed for the coinsurance and deductible under Medicare guidelines. Ch. 3 Index 21 Revision 4/1/17 Provider Responsibilities________________________________________________________ 3.2.2.2 Accepting a Client as Medicaid After Billing the Client If the provider collected money from the client for services rendered during the eligibility period and decides later to accept the client as a Medicaid client, and receive payment from Medicaid: Prior to submitting the claim to Medicaid, the provider must refund the entire amount previously collected from the client to him or her for the services rendered; and The 12-month timely filing deadline will not be waived (6.20, Timely Filing). In cases of retroactive eligibility when a provider agrees to bill Medicaid for services provided during the retroactive eligibility period: Prior to billing Medicaid, the provider must refund the entire amount previously collected from the client to him or her for the services rendered; and The twelve month timely filing deadline will be waived (6.20, Timely Filing). NOTE: Medicaid will not pay for services rendered to the clients until eligibility has been determined for the month services were rendered. The provider may, at a subsequent date, decide not to further treat the client as a Medicaid patient. If this occurs, the provider must advise the client of this fact in writing before rendering treatment. 3.2.2.3 Mutual Agreements Between the Provider & Client Medicaid covers only those services that are medically necessary and cost-efficient. It is the providers’ responsibility to be knowledgeable regarding covered services, limitations and exclusions of the Medicaid Program. Therefore, if the provider, without mutual written agreement of the client, deliver services and are subsequently denied Medicaid payment because the services were not covered or the services were covered but not medically necessary and/or cost-efficient, the provider may not obtain payment from the client. If the provider and the client mutually agree in writing to services which are not covered (or are covered but are not medically necessary and/or cost-efficient), and the provider informs the client of his/her financial responsibility prior to rendering service, then the provider may bill the client for the services rendered. 3.2.3 Ch. 3 Index Missed Appointments 22 Revision 4/1/17 Provider Responsibilities________________________________________________________ Appointments missed by Medicaid clients cannot be billed to Medicaid. However, if a provider’s policy is to bill all patients for missed appointments, then the provider may bill Medicaid clients directly. Any policy must be equally applied to all clients and a provider may not impose separate charges on Medicaid clients, regardless of payment source. Policy must be publically posted or provided in writing to all patients. Medicaid only pays providers for services they render (i.e., services as identified in 1905 (a) of the Social Security Act). They must accept that payment as full reimbursement for their services in accordance with 42 CFR 447.15. Missed appointments are not a distinct, reimbursable Medicaid service. Rather, they are considered part of a provider’s overall cost of doing business. The Medicaid reimbursement rates set by the State are designed to cover the cost of doing business. 3.3 Medicare Covered Services Claims for services rendered to clients eligible for both Medicare and Medicaid which are furnished by an out-of-state provider must be filed with the Medicare intermediary or carrier in the state in which the provider is located. Questions concerning a client’s Medicare eligibility should be directed to the Social Security Administration (2.1, Quick Reference). 3.4 Medical Necessity The Medicaid Program is designed to assist eligible clients in obtaining medical care within the guidelines specified by policy. Medicaid will pay only for medical services that are medically necessary and are sponsored under program directives. Medically necessary means the service is required to: Diagnose Treat Cure Prevent an illness which has been diagnosed or is reasonably suspected to: o Relieve pain o Improve and preserve health o Be essential for life Additionally, the service must be: Consistent with the diagnosis and treatment of the patient’s condition. In accordance with standards of good medical practice. Required to meet the medical needs of the patient and undertaken for reasons other than the convenience of the patient or his/her physician. Ch. 3 Index 23 Revision 4/1/17 Provider Responsibilities________________________________________________________ Performed in the least costly setting required by the patient’s condition. Documentation which substantiates that the client’s condition meets the coverage criteria must be on file with the provider. All claims are subject to both pre-payment and post-payment review for medical necessity by Medicaid. Should a review determine that services do not meet all the criteria listed above, payment will be denied or, if the claim has already been paid, action will be taken to recoup the payment for those services. 3.5 Medicaid Payment is Payment in Full As a condition of becoming a Medicaid provider (see provider agreement), the provider must accept payment from Medicaid as payment in full for a covered service. The provider may never bill a Medicaid client: When the provider bills Medicaid for a covered service, and Medicaid denies the providers claim due to billing errors such as wrong procedure and diagnosis codes, lack of prior authorization, invalid consent forms, missing attachments or an incorrectly filled out claim form. When Medicare or another third party payer has paid up to or exceeded what Medicaid would have paid. For the difference in the providers charges and the amount Medicaid has paid (balance billing). The Provider may bill a Medicaid client: If the provider has not billed Medicaid, the service provided is not covered by Medicaid, and prior to providing service, the provider informed the client in writing that the service is non-covered and he/she is responsible for the charges. If a provider does not accept a patient as a Medicaid client (because they cannot produce a Medicaid ID card or because they did not inform the provider they are eligible. If the client is not Medicaid eligible at the time the provider provides the services or on a plan that does not cover those particular services. Refer to the table above for guidance. If the client has exceeded the Medicaid limits on physical therapy, occupational therapy, speech therapy, behavioral health services, chiropractic services, prescriptions, and/or office/outpatient hospital visits. (6.9, Cap Limits) Ch. 3 Index 24 Revision 4/1/17 Provider Responsibilities________________________________________________________ NOTE: The provider may contact Provider Relations or the IVR to receive cap limits for a client (2.1, Quick Reference). If the provider is an out-of-state provider and are not enrolled and have no intention of enrolling. 3.6 Medicaid ID Card It is each provider’s responsibility to verify the person receiving services is the same person listed on the card. If necessary, providers should request additional materials to confirm identification. It is illegal for anyone other than the person named on the Medicaid ID Card to obtain or attempt to obtain services by using the card. Providers who suspect misuse of a card should report the occurrence to the Program Integrity Unit or complete the Report of Suspected Abuse of the Medicaid Healthcare System Form (4.9, Referral of Suspected Fraud and Abuse). 3.7 Verification of Client Age Because certain services have age restrictions, such as services covered only for clients under the age of 21, and informed consent for sterilizations, providers should verify a client’s age before a service is rendered. Routine services may be covered through the month of the client’s 21st birthday. 3.8 Verification Options One (1) Medicaid ID Card is issued to each client. Their eligibility information is updated every month. The presentation of a card is not verification of eligibility. It is each provider’s responsibility to ensure that their patient is eligible for the services rendered. A client may state that he/she is covered by Medicaid, but not have any proof of eligibility. This can occur if the client is newly eligible or if his/her card was lost. Providers have several options when checking patient eligibility. 3.8.1 Free Services The following is a list of free services offered by Medicaid for verifying client eligibility: Contact Provider Relations. There is a limit of three (3) verifications per call but no limit on the number of calls. Fax a list of identifying information to Provider Relations for verification. Send a list of beneficiaries for verification and receive a response within ten (10) business days. Ch. 3 Index 25 Revision 4/1/17 Provider Responsibilities________________________________________________________ Call the Interactive Voice Response (IVR) System. IVR is available 24-hours a day, seven (7) days a week. The IVR System allows 30 minutes per phone call. (2.1, Quick Reference). Use the Ask Wyoming Medicaid feature on the Secured Provider Web Portal (2.1, Quick Reference). 3.8.2 Fee for Service Several independent vendors offer web-based applications and/or swipe card readers that electronically check the eligibility of Medicaid clients. These vendors typically charge a monthly subscription and/or transaction fee. A complete list of approved vendors is available on the Medicaid website. 3.9 Freedom of Choice Any eligible non-restricted client may select any provider of health services in Wyoming who participates in the Medicaid Program, unless Medicaid specifically restricts his/her choice through provider lock-in or an approved Freedom of Choice waiver. However, payments can be made only to health service providers who are enrolled in the Medicaid Program. 3.10 Out-of-State Service Limitations Medicaid covers services rendered to Medicaid clients when providers participating in the Medicaid Program administer the services. If services are available in Wyoming within a reasonable distance from the client’s home, the client must not utilize an out-of-state provider. Medicaid has designated the Wyoming Medical Service Area (WMSA) to be Wyoming and selected border cities in adjacent states. WMSA cities include: Colorado Craig Idaho Montpelier Pocatello Idaho Falls Montana Billings Bozeman Nebraska Kimball Scottsbluff South Dakota Deadwood Custer Rapid City Spearfish Belle Fourche Utah Salt Lake City Ogden Ch. 3 Index 26 Revision 4/1/17 Provider Responsibilities________________________________________________________ NOTE: The cities of Greeley, Fort Collins, and Denver, Colorado are excluded from the WMSA and are not considered border cities. Medicaid compensates out-of-state providers within the WMSA when: The service is not available locally and the border city is closer for the Wyoming resident than a major city in Wyoming; and The out-of-state provider in the selected border city is enrolled in Medicaid. Medicaid compensates providers outside the WMSA only under the following conditions: Emergency Care – When a client is traveling and an emergency arises due to accident or illness. Other Care – When a client is referred by a Wyoming physician to a provider outside the WMSA for services not available within the WMSA. The referral must be documented in the provider’s records. Prior authorization is not required unless the specific service is identified as requiring prior authorization (6.14, Prior Authorization). Children in out-of-state placement. If the provider is an out-of-state, non-enrolled provider and renders services to a Medicaid client, the provider may choose to enroll in the Medicaid Program and submit the claim according to Medicaid billing instructions, or bill the client. Out-of-state providers furnishing services within the state on a routine or extended basis must meet all of the certification requirements of the State of Wyoming. The provider must enroll in Medicaid prior to furnishing services. 3.11 Record Keeping, Retention and Access 3.11.1 Requirements The Provider Agreement requires that the medical and financial records fully disclose the extent of services provided to Medicaid clients. The following elements include but are not limited to: The record must be typed or legibly written. The record must identify the client on each page. The record must contain a preliminary working diagnosis and the elements of a history and physical examination upon which the diagnosis is based. All services, as well as the treatment plan, must be entered in the record. Any drugs prescribed as part of a treatment, including the quantities and the Ch. 3 Index 27 Revision 4/1/17 Provider Responsibilities________________________________________________________ dosage, must be entered in the record. For any drugs administered, the NDC on the product must be recorded, as well as the lot number and expiration date. The record must indicate the observed medical condition of the client, the progress at each visit, any change in diagnosis or treatment, and the client’s response to treatment. Progress notes must be written for every service, including, but not limited to: office, clinic, nursing home, or hospital visits billed to Medicaid. Total treatment minutes of the client, including those minutes of active treatment reported under the timed codes and those minutes represented by the untimed codes, must be documented separately, to include beginning time and ending time for services billed. NOTE: 3.11.2 Specific or additional documentation requirements may be listed in the covered services sections or designated policy manuals. Retention of Records The provider must retain medical and financial records, including information regarding dates of service, diagnoses, and services provided, and bills for services for at least six (6) years from the end of the State fiscal year (July through June) in which the services were rendered. If an audit is in progress, the records must be maintained until the audit is resolved. 3.11.3 Access to Records Under the Provider Agreement, the provider must allow access to all records concerning services and payment to authorized personnel of-Medicaid, CMS Comptroller General of the United States, State Auditor’s Office (SAO), the Office of the Inspector General (OIG), the Wyoming Attorney General’s Office, the United States Department of Health and Human Services, and/or their designees. Records must be accessible to authorized personnel during normal business hours for the purpose of reviewing, copying and reproducing documents. Access to the provider records must be granted regardless of the providers continued participation in the program. In addition, the provider is required to furnish copies of claims and any other documentation upon request from Medicaid and/or their designee. 3.11.4 Audits Medicaid has the authority to conduct routine audits to monitor compliance with program requirements. Audits may include, but are not limited to: Ch. 3 Index 28 Revision 4/1/17 Provider Responsibilities________________________________________________________ Examination of records; Interviews of providers, their associates, and employees; Interviews of clients; Verification of the professional credentials of providers, their associates, and their employees; Examination of any equipment, stock, materials, or other items used in or for the treatment of clients; Examination of prescriptions written for clients; Determination of whether the healthcare provided was medically necessary; Random sampling of claims submitted by and payments made to providers; and/or Audit of facility financial records for reimbursement. Actual records reviewed may be extrapolated and applied to all services billed by the provider. The provider must grant the State and its representative’s access during regular business hours to examine medical and financial records related to healthcare billed to the program. Medicaid notifies the provider before examining such records. Medicaid reserves the right to make unscheduled visits i.e., when the client’s health may be endangered, when criminal/fraud activities are suspected, etc. Medicaid is authorized to examine all provider records in that: All eligible clients have granted Medicaid access to all personal medical Ch. 3 Index records developed while receiving Medicaid benefits. All providers who have at any time participated in the Medicaid Program, by signing the Provider Agreement, have authorized the State and their designated agents to access the provider’s financial and medical records. Provider’s refusal to grant the State and its representative’s access to examine records or to provide copies of records when requested may result in: Immediate suspension of all Medicaid payments. All Medicaid payments made to the provider during the six (6)-year record retention period for which records supporting such payments are not produced shall be repaid to the Division of Healthcare Financing after written request for such repayment is made. Suspension of all Medicaid payments furnished after the requested date of service. Reimbursement will not be reinstated until adequate records are produced or are being maintained. Prosecution under the Wyoming Statute. 29 Revision 4/1/17 Provider Responsibilities________________________________________________________ 3.12 Tamper Resistant RX Pads On May 25, 2007, Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007 was signed into law. The above law requires that ALL written, non-electronic prescriptions for Medicaid outpatient drugs must be executed on tamper-resistant pads in order for them to be reimbursable by the federal government. All prescriptions paid for by Medicaid must meet the following requirements to help insure against tampering: Written Prescriptions: As of October 1, 2008 prescriptions, must contain all three (3) of the following characteristics: 1. One (1) or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form. In order to meet this requirement all written prescriptions must contain: Some type of “void” or illegal pantograph that appears if the prescription is copied. May also contain any of the features listed within category one, recommendations provided by the National Council for Prescription Drug Programs (NCPDP) or that meets the standards set forth in this category. 2. One (1) or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber. This requirement applies only to prescriptions written for controlled substances. In order to meet this requirement all written prescriptions must contain: Quantity check-off boxes PLUS numeric form of quantity values OR alpha and numeric forms of quantity value. Refill Indicator (circle or check number of refills or “NR”) PLUS numeric form of refill values OR alpha AND numeric forms of refill values. May also contain any of the features listed within category two, recommendations provided by the NCPDP, or that meets the standards set forth in this category. 3. One (1) or more industry-recognized features designed to prevent the use of counterfeit prescription forms. In order to meet this requirement all written prescriptions must contain: Security features and descriptions listed on the FRONT of the prescription blank. May also contain any of the features listed within category three (3), recommendations provided by the NCPDP, or that meets that standards set forth in this category. Ch. 3 Index 30 Revision 4/1/17 Provider Responsibilities________________________________________________________ Computer Printed Prescriptions: As of October 1, 2008 prescriptions, must contain all three (3) of the following characteristics: 1. One (1) or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form. In order to meet this requirement all prescriber’s computer generated prescriptions must contain: Same as Written Prescription for this category. 2. One (1) or more industry-recognized features designed to prevent the erasure or modification of information printed on the prescription by the prescriber. In order to meet this requirement all computer generated prescriptions must contain: Same as Written Prescription for this category. 3. One (1) or more industry-recognized features designed to prevent the use of counterfeit prescription forms. In order to meet this requirement all prescriber’s computer generated prescriptions must contain: Security features and descriptions listed on the FRONT or BACK of the prescription blank. May also contain any of the features listed within category three (3), recommendations provided by the NCPDP, or that meets the standards set forth in this category. In addition to the guidance outlined above, the tamper-resistant requirement does not apply when a prescription is communicated by the prescriber to the pharmacy electronically, verbally, or by fax; when a managed care entity pays for the prescription; or in most situations when drugs are provided in designated institutional and clinical settings. The guidance also allows emergency fills with a non-compliant written prescription as long as the prescriber provides a verbal, faxed, electronic, or compliant written prescription within 72-hours. Audits of pharmacies will be performed by the Wyoming Department of Health, to ensure that the above requirement is being followed. If the provider has any questions about these audits or this regulation, please contact the Pharmacy Program Manager at (307)777-7531. Ch. 3 Index 31 Revision 4/1/17 Utilization Review______________________________________________________________ Chapter Four – Utilization Review 4.1 Utilization Review ............................................................................................... 33 4.2 Complaint Referral .............................................................................................. 33 4.3 Release of Medical Records ................................................................................ 33 4.4 Client Lock-In ..................................................................................................... 34 4.5 Pharmacy Lock-In ............................................................................................... 34 4.6 Hospice Lock-In .................................................................................................. 35 4.7 Fraud and Abuse .................................................................................................. 35 4.8 Provider Responsibilities ..................................................................................... 36 4.9 Referral of Suspected Fraud and Abuse .............................................................. 36 4.9.1 Report of Suspected Abuse of the Medicaid Healthcare System ........................ 37 4.10 Sanctions ............................................................................................................. 37 4.11 Adverse Actions .................................................................................................. 38 Ch. 4 Index 32 Revision 4/1/17 Utilization Review______________________________________________________________ 4.1 Utilization Review The Division of Healthcare Financing (DHCF) has established a Program Integrity Unit whose duties include, but are not limited to: 4.2 Review of claims submitted for payment (pre and post payment reviews) Review of medical records and documents related to covered services Audit of medical records and client interviews Review of client Explanation of Medical Benefits (EOMB) responses Operation of the Surveillance/Utilization Review (SUR) process Provider screening and monitoring Program compliance and enforcement Complaint Referral The Program Integrity Unit reviews complaints regarding inappropriate use of services from providers and clients. No action is taken without a complete investigation. To file a complaint, please submit the details in writing and attach supporting documentation to: Program Integrity Unit Division of Healthcare Financing 6101 Yellowstone Rd., Suite 210 Cheyenne, WY 82002 Or contact: (855) 846-2563 Or email: programintegrity@wyo.gov 4.3 Release of Medical Records Every effort is made to ensure the confidentiality of records in accordance with Federal Regulations and Wyoming Medicaid Rules. Medical records must be released to the agency or its designee. The signed Provider Agreement allows the Division of Healthcare Financing or its designated agent’s access to all medical and financial records. In addition, each client agrees to the release of medical records to the Division of Healthcare Financing when they accept Medicaid benefits. The Division of Healthcare Financing will not reimburse for the copying of medical records when the Division or its designated agents requests records. Ch. 4 Index 33 Revision 4/1/17 Utilization Review______________________________________________________________ 4.4 Client Lock-In In designated circumstances, it may be necessary to restrict certain services or “lockin” a client to a certain physician, hospice, pharmacy or other provider. If a lock-in restriction applies to a client, the lock-in information is provided on the Interactive Voice Response System (2.1, Quick Reference). A participating Medicaid provider who is not designated as the client’s primary practitioner may provide and be reimbursed for services rendered to lock-in clients only under the following circumstances: In a medical emergency where a delay in treatment may cause death or result in lasting injury or harm to the client. As a physician covering for the designated primary physician or on referral from the designated primary physician. In cases where lock-in restrictions are indicated, it is the responsibility of each provider to determine whether he/she may bill for services provided to a lock-in client. Contact Provider Relations in circumstances where coverage of a lock-in client is unclear. Refer to the Medicaid Pharmacy Provider Manual (2.1, Quick Reference). 4.5 Pharmacy Lock-In The Medicaid Pharmacy Lock-In Program limits certain Medicaid clients to receiving prescription services from multiple prescribers and utilizes multiple pharmacies within a designated time period is a candidate for the Lock-In Program. When a pharmacy is chosen to be a client’s designated Lock-In provider, notification is sent to that pharmacy with all important client identifying information. If a Lock-In client attempts to fill a prescription at a pharmacy other than their Lock-In pharmacy, the claim will be denied with an electronic response of “NON-MATCHED PHARMACY NUMBER-Pharmacy Lock-In”. Pharmacies have the right to refuse Lock-In provider status for any client. The client may be counseled to contact the Medicaid Pharmacy Case Manager at (307)777-8773 in order to obtain a new provider designation form to complete. Expectations of a Medicaid designated Lock-In pharmacy: Medicaid pharmacy providers should be aware of the Pharmacy Lock-In Program and the criteria for client lock-in status as stated above. The entire pharmacy staff should be notified of current Lock-In clients. Review and monitor all drug interactions, allergies duplicate therapy, and seeking of medications from multiple prescribers. Be aware that the client is locked-in when “refill too soon” or “therapeutic duplication” edits occur. Cash payment for controlled substances should serve as an alert and require further review. Gather additional information which may include, but is not limited to, asking the client for more information and/or contacting the prescriber. Document findings and outcomes. The Wyoming Board of Pharmacy will be Ch. 4 Index 34 Revision 4/1/17 Utilization Review______________________________________________________________ contacted when early refills and cash payment are allowed without appropriate clinical care and documentation. When doctor shopping for controlled substances is suspected, please contact the Medicaid Pharmacy Case Manager at (307)777-8773. The Wyoming Online Prescription Database (WORx) is online with 24/7 access for practitioners and pharmacists. The WORx program is managed by the Wyoming Board of Pharmacy at http://worxpdmp.com/ to view client profiles with all scheduled II through IV prescriptions the client has received. The Wyoming Board of Pharmacy may be reached at (307)634-9636 to answer questions about WORx. EMERGENCY LOCK-IN PRESCRIPTIONS If the dispensing pharmacist feels that in his/her professional judgment a prescription should be filled and they are not the Lock-In provider, they may submit a hand-billed claim to Goold Health Systems (GHS), an Emdeon company for review (2.1, Quick Reference). Overrides may be approved for true emergencies (auto accidents, sudden illness, etc.). Any Wyoming Medicaid client suspected of controlled substance abuse, diversion, or doctor shopping should be referred to the Medicaid Pharmacy Case Manager. Pharmacy Case Manager (307)777-8773 or Fax referrals to (307)777-6964. Referral forms may be found on the Pharmacy website (2.1, Quick Reference). 4.6 Hospice Lock-In Clients requesting coverage of hospice services under Wyoming Medicaid are lockedin to the hospice for all care related to their terminal illness. All services and supplies must be billed to the hospice provider, and the hospice provider will bill Wyoming Medicaid for covered services. For more information regarding the hospice program, refer to the Institutional Provider Manual on the Medicaid website (2.1, Quick Reference). 4.7 Fraud and Abuse The Medicaid Program operates under the anti-fraud provisions of Section 1909 of the Social Security Act, as amended, and employs utilization management, surveillance, and utilization review. The Program Integrity Unit’s function is to perform pre- and post-payment review of services funded by Medicaid. Surveillance is defined as the process of monitoring for service and controlling improper or illegal utilization of the program. While the surveillance function addresses administrative concerns, utilization review addresses medical concerns and may be defined as monitoring and controlling the quality and appropriateness of medical services Ch. 4 Index 35 Revision 4/1/17 Utilization Review______________________________________________________________ delivered to Medicaid clients. Medicaid may utilize the services of a Professional Review Organization (PRO) to assist in these functions. Since payment of claims is made from both State and Federal funds, submission of false or fraudulent claims, statements, documents or concealment of material facts may be prosecuted as a felony in either Federal or State court. The program has processes in place for referral to the Medicaid Fraud Control Unit (MFCU) when suspicion of fraud and abuse arise. Medicaid has the responsibility, under Federal Regulations and Medicaid Rules, to refer all cases of credible allegations of fraud and abuse to the MFCU. In accordance with 42 CFR Part 455, and Medicaid Rules, the following definitions of fraud and abuse are used: 4.8 Fraud “An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.” Abuse “Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid Program.” Provider Responsibilities The provider is responsible for reading and adhering to applicable State and Federal regulations and the requirements set forth in this manual. The provider is also responsible for ensuring that all employees are likewise informed of these regulations and requirements. The provider certifies by his/her signature or the signature of his/her authorized agent on each claim or invoice for payment that all information provided to Medicaid is true, accurate, and complete. Although claims may be prepared and submitted by an employee, billing agent or other authorized person, providers are responsible for ensuring the completeness and accuracy of all claims submitted to Medicaid. 4.9 Referral of Suspected Fraud and Abuse If a provider becomes aware of possible fraudulent or program abusive conduct/activity by another provider, or eligible client, the provider should notify the Program Integrity Unit in writing. Return a completed Report of Suspected Abuse of the Medicaid Healthcare System to or call or reference the below website: Ch. 4 Index 36 Revision 4/1/17 Utilization Review______________________________________________________________ Program Integrity Unit Division of Healthcare Financing 6101 Yellowstone Rd., Suite 210 Cheyenne, WY 82002 Or contact: (855)846-2563 http://stopmedicaidfraud.wyo.gov/ 4.9.1 Report of Suspected Abuse of the Medicaid Healthcare System NOTE: Click image above to be taken to a printable version of this form. 4.10 Sanctions The Division of Healthcare Financing (DHCF) may invoke administrative sanctions against a Medicaid provider when a credible allegation of fraud abuse, waste, noncompliance (i.e., Provider Agreement and/or Medicaid Rules) exists or who is under sanction by another regulatory entity (i.e. Medicare, licensing boards, OIG, or other Medicaid designated agents). Providers who have had sanctions levied against them may be subject to prohibitions or additional requirements as defined by Medicaid Rules (2.1, Quick Reference). Ch. 4 Index 37 Revision 4/1/17 Utilization Review______________________________________________________________ 4.11 Adverse Actions Providers and clients have the right to request an administrative hearing regarding an adverse action, after reconsideration, taken by the Division of Healthcare Financing. This process is defined in Wyoming Medicaid Rule, Chapter 4, entitled “Medicaid Administrative Hearings”. Ch. 4 Index 38 Revision 4/1/17 Client Eligibility_______________________________________________________________ Chapter Five – Client Eligibility 5.1 What is Medicaid? ............................................................................................... 40 5.2 Who is Eligible? .................................................................................................. 40 5.2.1 Children ............................................................................................................... 40 5.2.2 Pregnant Women ................................................................................................. 41 5.2.3 Family MAGI Adult ............................................................................................ 41 5.2.4 Aged, Blind and Disabled ................................................................................... 41 5.2.4.1 Supplemental Security Income (SSI) and SSI Related .................................... 41 5.2.4.2 Institution ......................................................................................................... 41 5.2.4.3 Home and Community Based Waiver ............................................................. 42 5.2.5 Other .................................................................................................................... 42 5.2.5.1 Special Groups ................................................................................................. 42 5.2.5.2 Employed Individuals with Disabilities (EID) ................................................ 42 5.2.5.3 Medicare Savings Programs ............................................................................ 42 5.2.5.4 Non-Citizens with Medical Emergencies (ALEN) .......................................... 43 5.3 Maternal and Child Health (MCH) ..................................................................... 43 5.4 Eligibility Determination ..................................................................................... 43 5.4.1 Applying for Medicaid ........................................................................................ 43 5.4.2 Determination ...................................................................................................... 44 5.5 Client Identification Cards .................................................................................. 44 5.6 Other Types of Eligibility Identification ............................................................. 45 5.6.1 Ch. 5 Index Medicaid Approval Notice .................................................................................. 45 39 Revision 4/1/17 Client Eligibility_______________________________________________________________ 5.1 What is Medicaid? Medicaid is a health coverage program jointly funded by the Federal government and the State of Wyoming. The program is designed to help pay for medically necessary healthcare services for children, pregnant women, family Modified Adjusted Gross Income (MAGI) adults and the aged, blind and disabled. 5.2 Who is Eligible? Eligibility is generally based on family income and sometimes resources and/or healthcare needs. Federal statutes define more than 50 groups of individuals that may qualify for Medicaid coverage. There are four (4) broad categories of Medicaid eligibility in Wyoming: 5.2.1 Children; Pregnant women; Family MAGI Adults; and Aged, Blind, and Disabled. Children Newborns are automatically eligible if the mother is Medicaid eligible at the Ch. 5 Index time of the birth. Low Income Children are eligible if family income is at or below 133% federal poverty level (FPL) or 154% FPL, dependent on age of the child. Presumptive Eligibility (PE) for Children allows temporary coverage for a child who meets eligibility criteria for the full Children's Medicaid program while the full Medicaid application is being processed. o PE Coverage will end the date a determination is made on the full Medicaid application or the last day of the next month after PE is approved if a full Medicaid application is not submitted. Foster Care Children in Department of Family Services (DFS) custody are eligible in different income levels including some who enter subsidized adoption or who age out of foster care until they are age 26. Presumptive Eligibility (PE) for Former Foster Youth allows temporary coverage for a person who meets eligibility criteria for the full Former Foster Youth Medicaid program while the full Medicaid application is being processed. o PE Coverage will end the date a determination is made on the full Medicaid application or the last day of the next month after PE is approved if a full Medicaid application is not submitted. 40 Revision 4/1/17 Client Eligibility_______________________________________________________________ 5.2.2 Pregnant Women Pregnant Women are eligible if family income is at or below 154% FPL. Women with income less than or equal to the MAGI conversion of the 1996 Family Care Standard must cooperate with child support to be eligible. Presumptive Eligibility (PE) for Pregnant Women allows temporary outpatient coverage for a pregnant woman who meets eligibility criteria for the full Pregnant Woman Medicaid program while the full Medicaid application is being processed. o PE Coverage will end the date a determination is made on the full Medicaid application or the last day of the next month after PE is approved if a full Medicaid application is not submitted. 5.2.3 Family MAGI Adult Family MAGI Adults (caretaker relatives with a dependent child) are eligible if family income is at or below the MAGI conversion of the 1996 Family Care Standard. Presumptive Eligibility (PE) for Caretaker Relatives allows temporary coverage for the parent or caretaker relative of a Medicaid eligible child who meets eligibility criteria for the full Family MAGI Medicaid program while the full Medicaid application is being processed. o PE Coverage will end the date a determination is made on the full Medicaid application or the last day of the next month after PE is approved if a full Medicaid application is not submitted. 5.2.4 Aged, Blind and Disabled 5.2.4.1 Supplemental Security Income (SSI) and SSI Related SSI – A person receiving SSI automatically qualifies for Medicaid SSI Related – A person no longer receiving SSI payment may be eligible using SSI criteria. 5.2.4.2 Institution All categories are income eligible up to 300% SSI Standard. Ch. 5 Index Nursing Home Hospital Hospice ICF ID – Wyoming Life Resource Center INPAT-PSYCH – WY State Hospital – clients are 65 years and older. 41 Revision 4/1/17 Client Eligibility_______________________________________________________________ 5.2.4.3 Home and Community Based Waiver All waiver groups are income eligible when income is less than or equal to 300% SSI Standard. 5.2.5 Acquired Brain Injury Assisted Living Facilities Children’s Mental Health Comprehensive Long Term Care Supports Other 5.2.5.1 Special Groups Breast and Cervical Cancer (BCC) Treatment Program – Uninsured women diagnosed with breast or cervical cancer are income eligible at or below 250% FPL Presumptive Eligibility (PE) for BCC allows temporary coverage for a woman who meets eligibility criteria for the full BCC Medicaid program while the full Medicaid application is being processed. o PE Coverage will end the date a determination is made on the full Medicaid application or the last day of the next month after PE is approved if a full Medicaid application is not submitted. Tuberculosis (TB) Program – Individuals diagnosed with tuberculosis are eligible based on the TB Standard. Program for All Inclusive Care for the Elderly (PACE) – Individuals over the age of 55 assessed to be in need of nursing home level of care receive all services coordinated through the PACE provider. This program is currently available in Laramie County only. 5.2.5.2 Employed Individuals with Disabilities (EID) Employed Individuals with Disabilities are income eligible when income is less than or equal to 300% SSI using unearned income and must pay a premium calculated using total gross income. 5.2.5.3 Medicare Savings Programs Qualified Medicare Beneficiaries (QMB) are income eligible at or below 100% FPL. Benefits include payment of Medicare premiums, deductibles, and cost sharing. Specified Low Income Beneficiaries (SLMB) are income eligible at or below 135% FPL. Benefits include payment of Medicare premiums only. Ch. 5 Index 42 Revision 4/1/17 Client Eligibility_______________________________________________________________ 5.2.5.4 Non-Citizens with Medical Emergencies (ALEN) A non-citizen who meets all eligibility factors under a Medicaid group except for citizenship and social security number is eligible for emergency services. This does not include dental services. 5.3 Maternal and Child Health (MCH) Maternal and Child Health (MCH) provides services for high-risk pregnant women, high-risk newborns and children with special healthcare needs through the Children’s Special Health (CSH) program. The purpose is to identify eligible clients, assure diagnostic and treatment services are available, provide payment for authorized specialty care for those eligible, and provide care coordination services. CSH does not cover acute or emergency care. A client may be eligible only for a MCH program or may be dually eligible for a MCH program or other Medicaid programs. Care coordination for both MCH only and dually eligible clients is provided through the Public Health Nurse (PHN). MCH has a dollar cap and limits on some services for those clients who are eligible for MCH only. Contact MCH for the following information: o The nearest Public Health Nurse (PHN) o Questions related to eligibility determination o Questions related to the type of services authorized by MCH. Maternal & Child Health 6101 N. Yellowstone Rd., Ste. 420 Cheyenne, WY 82002 (800)438-5795 or Fax: (307)777-7215 Providers must be enrolled with Medicaid and MCH to receive payment for MCH services. Claims for both programs are submitted to and processed by the fiscal agent for Wyoming Medicaid (2.1, Quick Reference). Providers are asked to submit the medical record to CSH in a timely manner assure coordination of referrals and services. 5.4 Eligibility Determination 5.4.1 Applying for Medicaid Persons applying for Children, Pregnant Women and/or Family MAGI Adult programs may complete the Application for Wyoming’s Healthcare Coverage, which is also used for the Kid Care CHIP program. The application may be Ch. 5 Index 43 Revision 4/1/17 Client Eligibility_______________________________________________________________ mailed to the Wyoming Department of Health (WDH). Applicants may also apply online at https://www.wesystem.wyo.gov/. Presumptive Eligibility (PE) applicants may also apply through a qualified provider or qualified hospital for the PE programs. 5.4.2 Determination Eligibility determination is conducted by the Wyoming Department of Health Customer Service Center (CSC) or the Long Term Care (LTC) Unit centrally located in Cheyenne, WY (2.1, Quick Reference). Persons who want to apply for other programs offered through the Department of Family Services (DFS), such as Supplemental Nutrition Assistance Program (SNAP) or Child Care need to apply in person at their local DFS office. Persons applying for Supplemental Security Income (SSI) need to contact the Social Security Administration (SSA) (2.1, Quick Reference). Medicaid assumes no financial responsibility for services rendered prior to the effective date of client eligibility as determined by the WDH or the SSA. However, the effective date of eligibility as determined by the WDH may be retroactive up to 90-days prior to the month in which the application is filed, as long as the client meets eligibility criteria during each month of the retroactive period. If the SSA deems the client eligible, the period of original entitlement could precede the application date beyond the 90-day retroactive eligibility period and/or the 12-month timely filing deadline for Medicaid claims (6.20, Timely Filing). This situation could arise for the following reasons: Administrative Law Judge decisions or reversals. Delays encountered in processing applications or receiving necessary client information concerning income or resources. 5.5 Client Identification Cards A Medicaid ID Card is mailed to clients upon enrollment in the Medicaid Program or other health programs such as the AIDS Drug Assistance Program (ADAP), Children’s Special Health (CSH), and Prescription Drug Assistance Program (PDAP). Not all programs receive a Medicaid ID Card, to confirm if a plan generates a card or not refer to the “card” indicator on the Medicaid and State Benefit Plan Guide. Sample Medicaid ID card: Ch. 5 Index 44 Revision 4/1/17 Client Eligibility_______________________________________________________________ 5.6 Other Types of Eligibility Identification 5.6.1 Medicaid Approval Notice In some cases, a provider may be presented with a copy of a Medicaid Approval Notice in lieu of the client’s Medicaid ID Card. Providers should always verify eligibility before rendering services to a client who presents a Medicaid Approval Notice. NOTE: Ch. 5 Index Refer to “Verification Options” (3.8, Verification Options) on ways to verify a client’s eligibility. 45 Revision 4/1/17 Common Billing Information ____________________________________________________ Chapter Six – Common Billing Information 6.1 Electronic Billing ................................................................................................ 49 6.2 Basic Paper Claim Information ........................................................................... 49 6.3 Authorized Signatures ......................................................................................... 50 6.4 Completing the CMS-1500 Claim Form ............................................................. 51 6.4.1 Instructions for Completing the CMS-1500 Claim Form ................................... 51 6.4.2 Place of Service ................................................................................................... 56 6.5 Medicare Crossovers ........................................................................................... 61 6.5.1 General Information ............................................................................................ 61 6.5.2 Billing Information .............................................................................................. 62 6.6 Examples of Billing ............................................................................................. 63 6.6.1 Client has Medicaid Coverage Only or Medicaid and Medicare Coverage ........ 63 6.6.2 Client has Medicaid and Third Party Liability (TPL) or Client has Medicaid, Medicare and TPL ............................................................................................... 64 6.7 National Drug Code (NDC) Billing Requirement ............................................... 65 6.7.1 Converting 10-Digit NDC’s to 11-Digits ............................................................ 65 6.7.2 Documenting and Billing the Appropriate NDC ................................................. 66 6.7.3 Procedure Code/NDC Combinations .................................................................. 67 6.7.4 Billing Requirements ........................................................................................... 67 6.7.5 Submitting One NDC per Procedure Code ......................................................... 67 6.7.6 Submitting Multiple NDCs per Procedure Code ................................................. 68 6.7.7 Medicare Crossover Claims ................................................................................ 68 6.7.8 CMS-1500 02-12 Billing Instructions ................................................................. 68 6.8 Cap Limits ........................................................................................................... 69 6.8.1 Cap Limit Waiver ................................................................................................ 70 6.8.2 Cap Limit Waiver Request Form ........................................................................ 71 6.8.3 Cap Limit Waiver Request Form Instructions .................................................... 72 6.8.4 Cap Limit Additional Information for Clients Under the Age of 21 ................... 73 6.8.5 Cap Limit Additional Information Instructions................................................... 74 6.9 Ch. 6 Index Reimbursement Methodologies ........................................................................... 75 46 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.10 6.10.1 Usual and Customary Charges ............................................................................ 75 Invoice Charges ................................................................................................... 75 6.11 Co-Payment Schedule ......................................................................................... 76 6.12 How to Bill for Newborns ................................................................................... 76 6.13 Prior Authorization .............................................................................................. 76 6.13.1 Requesting Prior Authorization from Medical Policy ......................................... 77 6.13.1.1 Medicaid Prior Authorization Form ................................................................ 79 6.13.1.2 Instructions for Completing the Medicaid Prior Authorization Form ............. 79 6.13.2 Requesting an Emergency Prior Authorization ................................................... 81 6.13.2.1 Prior Authorization Approval .......................................................................... 81 6.13.2.2 Sample PA Approval Letter ............................................................................ 82 6.13.2.3 Prior Authorization Denial .............................................................................. 83 6.13.2.4 Sample Prior Authorization Denial Letter ....................................................... 83 6.13.2.5 Prior Authorization Pending ............................................................................ 84 6.13.2.6 Sample Prior Authorization Pending ............................................................... 84 6.14 6.14.1 6.15 6.15.1 6.16 6.16.1 Order vs Delivery Date........................................................................................ 85 Order vs Delivery Date Exception Form ............................................................. 86 Submitting Attachments for Electronic Claims................................................... 86 Attachment Cover Sheet ...................................................................................... 88 Sterilization, Hysterectomy and Abortion Consent Forms ................................. 88 Sterilization Consent Form and Guidelines......................................................... 88 6.16.1.1 Sterilization Consent Form .............................................................................. 90 6.16.1.2 Instructions for Completing the Sterilization Consent Form........................... 90 6.16.2 Hysterectomy Acknowledgment of Consent ....................................................... 90 6.16.2.1 Instructions for Completing the Hysterectomy Acknowledgment of Consent Form ................................................................................................................ 92 6.16.2.2 Hysterectomy Acknowledgment Consent Form.............................................. 93 6.16.3 Abortion Certification Guidelines ....................................................................... 93 6.16.3.1 Instructions for Completing the Abortion Certification Form......................... 93 6.16.3.2 Abortion Certification Form ............................................................................ 94 6.17 6.17.1 Ch. 6 Index Remittance Advice .............................................................................................. 94 Sample Professional Remittance Advice ............................................................ 96 47 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.17.2 How to Read the Remittance Advice .................................................................. 97 6.17.3 Remittance Advice Replacement Request Policy ............................................... 98 6.17.3.1 Remittance Advice (RA) Replacement Request Form .................................... 99 6.17.4 Obtain an RA from the Web................................................................................ 99 6.17.5 When a Client Has Other Insurance .................................................................... 99 6.18 Resubmitting Versus Adjusting Claims ............................................................ 100 6.18.1 How Long do Providers Have to Resubmit or Adjust a Claim? ....................... 100 6.18.2 Resubmitting a Claim ........................................................................................ 101 6.18.2.1 6.18.3 When to Resubmit to Medicaid ..................................................................... 101 Adjustment/Void Request Form Electronically Adjusting Paid Claims via Hardcopy/Paper ................................................................................................. 101 6.18.3.1 Adjustment/Void Request Form .................................................................... 102 6.18.3.2 How to Request an Adjustment/Void ............................................................ 102 6.18.3.3 How to Complete the Adjustment/Void Request Form................................. 103 6.18.3.4 When to Request an Adjustment ................................................................... 103 6.18.3.5 When to Request a Void ................................................................................ 104 6.19 Credit Balances.................................................................................................. 104 6.20 Timely Filing ..................................................................................................... 105 6.20.1 Exceptions to the Twelve-Month Limit ............................................................ 105 6.20.2 Appeal of Timely Filing .................................................................................... 106 6.20.2.1 How to Appeal ............................................................................................... 106 6.21 Important Information Regarding Retroactive Eligibility Decisions ................ 106 6.22 Client Fails to Notify a Provider of Eligibility .................................................. 107 6.23 Billing Tips to Avoid Timely Filing Denials .................................................... 107 6.24 Telehealth .......................................................................................................... 108 6.24.1 Covered Services ............................................................................................... 108 6.24.2 Non-Covered Services ....................................................................................... 110 6.24.3 Billing Requirements ......................................................................................... 110 Ch. 6 Index 48 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.1 Electronic Billing As of July 1, 2015 Wyoming Medicaid requires all providers to submit electronically. There are two (2) exceptions to this requirement: Providers who do not submit at least 25 claims in a calendar year. Providers who do not bill diagnosis codes on their claims. If a provider is unable to submit electronically, the provider must submit a request for an exemption in writing and must include: Provider name, NPI, contact name and phone number. The calendar year for which the exemption is being requested. Detailed explanation of the reason for the exemption request. Mail to: Wyoming Medicaid Attn: Provider Relations PO Box 667 Cheyenne, WY 82003-0667 A new exemption request must be submitted for each calendar year. Wyoming Medicaid has free software or applications available for providers to bill electronically (Chapter 8, Electronic Data Interchange (EDI)). 6.2 Basic Paper Claim Information The fiscal agent processes paper CMS-1500 and UB04 claims using Optical Character Recognition (OCR). OCR is the process of using a scanner to read the information on a claim and convert it into electronic format instead of being manually entered. This process improves accuracy and increases the speed at which claims are entered into the claims processing system. The quality of the claim will affect the accuracy in which the claim is processed through OCR. The following is a list of tips to aid providers in avoiding paper claims processing problems with OCR: Ch. 6 Index Use an original, standard, red-dropout form (CMS-1500 (02-12) and UB04). Use typewritten print; for best results use a laser printer. Use a clean, non-proportional font. Use black ink. Print claim data within the defined boxes on the claim form. Print only the information asked for on the claim form. Use all capital letters. 49 Revision 4/1/17 Common Billing Information ____________________________________________________ Use correction tape for corrections. To avoid delays in the processing of claims it is recommended that providers avoid the following: Using copies of claim forms. Faxing claims. Using fonts smaller than 8 point. Resizing the form. Handwritten information on the claim form. Entering “none”, “NA”, or “Same” if there is no information (leave the box blank). Mixing fonts on the same claim form. Using italics or script fonts. Printing slashed zeros. Using highlighters to highlight field information. Using stamps, labels, or stickers. Marking out information on the form with a black marker. Claims that do not follow Medicaid provider billing policies and procedures may be returned unprocessed with a letter or may be processed incorrectly. When a claim is returned the provider may correct the claim and return it to Medicaid for processing. NOTE: The fiscal agent and the Division of Healthcare Financing (DHCF) are prohibited by federal law from altering a claim. Billing errors detected after a claim is submitted cannot be corrected until after Medicaid has made payment or notified the provider of the denial. Providers should not resubmit or attempt to adjust a claim until it is reported on their Remittance Advice (6.18, Resubmitting Versus Adjusting Claims). NOTE: 6.3 Claims are to be submitted only after service(s) have been rendered, not before. For deliverable items (i.e. dentures, DME, glasses, hearing aids, etc.) the date of service must be the date of delivery, not the order date. Authorized Signatures All paper claims must be signed by the provider or the provider’s authorized representative. Acceptable signatures may be either handwritten, a stamped facsimile, typed, computer generated, or initialed. The signature certifies all information on the Ch. 6 Index 50 Revision 4/1/17 Common Billing Information ____________________________________________________ claim is true, accurate, complete, and contains no false or erroneous information. Remarks such as signature on file or facility names will not be accepted. 6.4 Completing the CMS-1500 Claim Form 6.4.1 Claim Item 1 Instructions for Completing the CMS-1500 Claim Form Title Required Insurance Type X 1a Insured’s ID Number X 2 Patient’s Name X 3 Patient’s Date of Birth/Sex Ch. 6 Index Conditionally Required Action/Description Place an "X" in the "Medicaid" box. Enter the client’s ten (10) digit Medicaid ID number that appears on the Medicaid Identification card. Enter the client’s last name, first name, and middle initial. Information that will identify the patient and distinguishes persons with similar names. 51 Revision 4/1/17 Common Billing Information ____________________________________________________ Claim Item Title Required Conditionally Required 4 Insured’s Name X 5 X 7 Patient’s Address Patient’s Relationship to Insured Insured’s Address 8 Patient Status Instruct ions for 9a-d Other Insurance Information 9 Other Insured’s Name 6 Other Insured’s Policy or Group Name Reserved for NUCC Use Reserved for NUCC Use Insurance Plan or Program Name 9a 9b 9c 9d 10a-c 10d 11 Is Patient’s Condition Related to? Reserved for Local Use Insured’s Policy, group or FECA Number X Enter the insured’s full last name, first name, and middle initial. Insured’s name identifies who holds the policy if different than Patient information. Refers to patient’s permanent residence. If the client is covered by other insurance, mark the appropriate box to show relationship. Enter the address of the insured. Indicates patient’s marital and employment status. X If item number 11d is marked complete fields 9 and 9a-d. X When additional group health coverage exists, enter other insured’s full last name, first name and middle initial of the enrollee if different from item number 2. X Enter the policy or group number of the other insured. X X X 11a Insured’s Date of Birth, Sex X 11b Insured’s Employer’s Name or School Name X Ch. 6 Index Action/Description 52 Enter the other insured’s insurance plan or program name. When appropriate, enter an X in the correct box to indicate whether one or more the services described in Item Number 24 are for a condition or injury the occurred on the job or as a result of an auto accident. Enter the insured’s policy or group number as it appears on the ID card. Only complete if Item Number 4 is completed. Enter the 8- digit date of birth (MM/DD/CCYY) and an X to indicate the sex of the insured. Enter the Name of the insured’s employer or school. Revision 4/1/17 Common Billing Information ____________________________________________________ Claim Item 11c 11d 12 13 14 15 16 Title Insurance Plan Name or Program Name Is there another Health Benefit Plan? Patient’s or Authorized Person’s Signature Payment Authorization Signature Date of current illness, injury or pregnancy If Patient has had Same or Similar Illness Date Patient Unable to Work in Current Occupation Required Enter the insurance plan or program name of the insured. X When appropriate, enter an X in the correct box. If marked “YES”, complete 9 and 9a-d. Enter the date of illness, injury or pregnancy. X A patient having had same or similar illness would indicate that the patient had a previously related condition. Time span the patient is or was unable to work. 17a 17a Other ID # X 17b NPI # X 20 X Indicates that there is a signature on file authorizing payment of medical benefits. 17 19 Enter the name and credentials of the professional who referred, ordered or supervised the service on the claim. Other ID number of the referring, ordering, or supervising provider is reported in 17a in the shaded area. The qualifier indicating what the number represents is reported in the qualifier field to the immediate right. Enter the NPI number of the referring, ordering, or supervising provider in Item Number 17b. The hospitalization dates related to current services would refer to an inpatient stay and indicates admission and discharge dates. Hospitalization Dates Related to Current Service Reserved for Local Use Indicates that services have been rendered by an independent provider as indicated in Item Number 32 and related Costs. Outside lab? $ Charges Ch. 6 Index Action/Description Indicates there is an authorization on file for the release of any medical or other information necessary to process the claim. Name of Referring Physician 18 Conditionally Required 53 Revision 4/1/17 Common Billing Information ____________________________________________________ Claim Item Title 21 ICD Indicator Diagnosis or Nature of Illness or Injury 22 Medicaid Resubmission Code 23 Prior Authorization 24 Claim Line Detail 24A Dates of Service X 24B Place of Service X 24C EMG X 24D Procedures, Services, or Supplies X Ch. 6 Index Required Conditionally Required X X 54 Action/Description Enter the ICD-9 or ICD-10 indicator Enter the patient’s diagnosis/condition. List up to twelve ICD-PCM codes. Use the highest level of specificity. Do not provide a description in this field. The code and original reference number assigned by the destination payer or receiver to indicate a previously submitted claim. Enter the ten (10) digit Prior Authorization number from the approval letter, if applicable. Claims for these services are subject to service limits and the 12 month filing limit. Supplemental information is to be placed in the shaded sections of 24A through 24G as required by individual payers. Medicaid requires information such as NDC and taxonomy in the shaded areas as defined in each Item Number Enter date(s) of service, from and to. If one (1) date of service only enter that date under “from”. Leave “to” blank or reenter “from” date. Enter as MM/DD/YY. NDC qualifier and NDC code will be placed in the shaded area. For detailed information on billing with the corresponding NDC codes, refer to the NDC entry information following this instruction table. Enter the two (2) digit Place of Service (POS) code for each procedure performed. This field is used to identify if the service was an emergency. Provider must maintain documentation supporting an emergency indicator. Enter Y for “YES” or leave blank or enter N for “NO” in the bottom, unshaded area of the field. This field is situational, but required when the service is deemed an emergency Enter the CPT or HCPCS codes and modifiers from the appropriate code set in effect on the date of service. Revision 4/1/17 Common Billing Information ____________________________________________________ Claim Item Title Required Conditionally Required 24E Diagnosis Pointer X 24F $ Charges X 24G Days or Units X 24H EPSDT/Family Plan X 24I ID Qualifier X 24J Rendering Provider ID # X 25 Federal Tax ID Number 26 Patient’s Account Number 27 Accept Assignment? X 28 Total Charge X 29 Amount Paid 30 Balance Due Ch. 6 Index X 55 Action/Description Enter the diagnosis code reference letter (pointer) as shown in Item Number 21 to relate the date of service and the procedures performed to the primary diagnosis. Do Not enter any diagnosis codes in this box. Enter the charge for each listed service. Enter the units of services rendered for each detail line. A unit of service is the number of times a procedure is performed. If only one (1) service is performed, the numeral 1 must be entered. Identifies certain services that may be covered under some state plans. If the provider does not have an NPI number, enter the appropriate qualifier and identifying number in the shaded area (Chapter 9, Wyoming Specific HIPAA 5010). The individual rendering the service is reported in 24J. Enter the taxonomy code in the shaded area of the field. Enter the NPI number in the un-shaded area of the field. Report the Identification Number in Items 24I and 24J only when different from the data in Items 33a and 33b. Refers to the unique identifier assigned by a federal or state agency. The patient’s account number refers to the identifier assigned by the provider (optional). Enter X in the correct box. Indicated that the provider agrees to accept assignment under the terms of the Medicare program. Add all charges in Column 24F and enter the total amount in this field. Enter total amount the patient or other payers paid on the covered services only. This field is reserved for third party coverage only, do not enter Medicare paid amounts Enter the total amount due. Revision 4/1/17 Common Billing Information ____________________________________________________ Claim Item Title 31 Signature of Physician or Supplier Including Degrees or Credentials 32, 32a and 32b Split Field 32 -Service Facility Location Information 32a NPI Number 32b Other ID# X 33, 33a and 33b Split Field 33 -Billing Provider Info & Ph# 33a NPI number 33b taxonomy X 6.4.2 Place of Service Required Conditionally Required Action/Description Enter the legal signature of the practitioner or supplier, signature of the practitioner or supplier representative. Enter date the form was signed. X Enter the name, address, city, state and zip code of the location where the services were rendered. Enter the NPI number of the service facility location in 32a; enter the two (2) digit qualifier identifying the non-NPI number followed by the ID number. Enter the provider’s or supplier’s billing name, address, zip code and phone number. Enter the NPI number of the billing provider in 33a. Enter the two (2) digit qualifier identifying the non-NPI number followed by the ID number. Enter the provider’s taxonomy number in 33b. Place of Service Place of Service Name 01 Pharmacy 02 03 Unassigned School 04 Homeless Shelter 05 Indian Health Service Freestanding Facility 06 Indian Health Service Providerbased Facility Ch. 6 Index Place of Service Description A facility or location where drugs and other medically related items and services are sold, dispensed, or otherwise provided directly to patients. N/A A facility whose primary purpose is education. A facility or location whose primary purpose is to provide temporary housing to homeless individuals (e.g., emergency shelters, individual or family shelters). A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services to American Indians and Alaska Natives who do not require hospitalization. A facility or location, owned and operated by the Indian Health Service, which provides diagnostic, therapeutic (surgical and non-surgical), and rehabilitation services rendered by, or under the supervision of, physicians to American Indians and Alaska Natives admitted as inpatients or outpatients. 56 Revision 4/1/17 Common Billing Information ____________________________________________________ Place of Service Place of Service Name 07 Tribal 638 Freestanding Facility 08 Tribal 638 Providerbased Facility 09 Prison/Correctional Facility 10 Unassigned 11 Office 12 Home 13 Assisted Living Facility 14 Group Home 15 Mobile Unit 16 Temporary Lodging Ch. 6 Index Place of Service Description A facility or location owned and operated a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members who do not require hospitalization. A facility or location owned and operated a federally recognized American Indian or Alaska Native tribe or tribal organization under a 638 agreement, which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation services to tribal members admitted as inpatients or outpatients. A prison, jail, reformatory, work farm, detention center, or any other similar facility maintained by either Federal, State, or local authorities for the purpose of confinement or rehabilitation of adult or juvenile criminal offenders. N/A Location, Other than a Hospital, Skilled Nursing Facility, Military treatment Facility, Community Health Center, State or Local Public Health Clinic, or Intermediate Care Facility, where the health professional routinely provides health examinations, diagnosis, and treatment of illness or injury on an ambulatory basis. Location, other than a Hospital or other Facility, where the patient receives care in a private session. Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24-hours a day, seven (7) days a week, with the capacity to deliver or arrange for services including some healthcare and other services. A residence, with shared living areas, where clients receive supervision and other services such as social and / or behavioral services, custodial service, and minimal services (e.g., medication administration. A facility / unit that moves from place-to-place equipped to provide preventive, screening, diagnostic, and / or treatment services. A short term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code. 57 Revision 4/1/17 Common Billing Information ____________________________________________________ Place of Service Place of Service Name 17 Walk-in Retail Health Clinic 18 Place of EmploymentWorksite 19 Unassigned 20 Urgent Care Facility 21 Inpatient Hospital 22 Outpatient Hospital 23 Emergency Room – Hospital 24 Ambulatory Surgical Center 25 Birthing Center 26 Military Treatment Facility 27-30 Unassigned Ch. 6 Index Place of Service Description A walk-in-health clinic, other than an office, urgent care facility, pharmacy or independent clinic and not described by any other Place of Service code, that is located within a retail operation and provides, on an ambulatory basis, preventive and primary care services. A location, not described by any other POS code, owned or operated by a public or private entity where the patient is employed, and where a health professional provides on-going or episodic occupational medical, therapeutic or rehabilitative services to the individual. N/A Location, distinct from a hospital emergency room, an office, or a clinic, whose purpose is to diagnose and treat illness or injury for unscheduled, ambulatory patients seeking immediate medical attention. A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions. A portion of a Hospital, which provides diagnostic, therapeutic (both surgical and non-surgical), and rehabilitation services to sick or injured persons who do not require Hospitalization or Institutionalization. A portion of a Hospital where emergency diagnosis and treatment of illness or injury is provided. A free standing facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis. A facility, other than a hospital’s maternity facilities or a physician’s office, which provides a setting for labor, delivery, and immediate post-partum care as well as immediate care of new born infants. A medical facility operated by one (1) or more of the Uniformed Services. Military Treatment Facility (MTF) also refers to certain former U.S. Public Health Services (USPHS) facilities now designated as Uniformed Service Treatment Facilities (USTF). N/A 58 Revision 4/1/17 Common Billing Information ____________________________________________________ Place of Service Place of Service Name 31 Skilled Nursing Facility 32 Nursing Facility 33 Custodial Care Facility 34 Hospice 35-40 Unassigned 41 Ambulance – Land 42 Ambulance – Air or Water 43-48 Unassigned 49 Independent Clinic 50 Federally Qualified Health Center 51 Inpatient Psychiatric Facility 52 Psychiatric FacilityPartial Hospitalization Ch. 6 Index Place of Service Description A facility, which primarily provides inpatient skilled, nursing care and related services to patients who require medical, nursing, or rehabilitation services but does not provide the level of care of treatment available on a hospital. A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of injured, disabled, or sick persons, or, on a regular basis, health-related care services above the level of custodial care to other than mentally retarded individuals. A facility which provides room, board and other personal assistance services, generally on a long-term basis, which does not include a medical component. A facility, other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided. N/A A land vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. An air or water vehicle specifically designed, equipped and staffed for lifesaving and transporting the sick or injured. N/A A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only. A facility located in a medically underserved area that provides Medicare beneficiaries preventive primary medical care under the general direction of a physician. A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24hour basis, by or under the supervision of a physician. A facility for the diagnosis and treatment of mental illness that provides a planned therapeutic program for patients who do not require full time hospitalization, but who need broader programs than are possible from outpatient visits to a hospital-bases or hospital-affiliated facility. 59 Revision 4/1/17 Common Billing Information ____________________________________________________ Place of Service Place of Service Name 53 Community Mental Health Center 54 Intermediate Care Facility / Mentally Retarded 55 Residential Substance Abuse Treatment Facility 56 Psychiatric Residential Treatment Center 57 Non-residential Substance Abuse Treatment Facility 58-59 Unassigned 60 Mass Immunization Center 61 Comprehensive Inpatient Rehabilitation Facility Ch. 6 Index Place of Service Description A facility that provides the following services: Outpatient services, including specialized outpatient services for children, the elderly, individuals who are chronically ill, and residents of the CMHC’s mental health services are who have been discharged from inpatient treatment at a mental health facility; 24-hour a day emergency care services; day treatment, other partial hospitalization services, or psychosocial rehabilitation services. A facility which primarily provides health-related care and services above the level of custodial care to mentally retarded individuals but does not provide the level of care or treatment available in a hospital or SNF. A facility which provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory test, drugs and supplies, psychological testing, and room and board. A facility or distinct part of a facility for psychiatric care which provides a total 24-hour therapeutically planned and professionally staffed group living and learning environment. A location which provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing. N/A A location where providers administer pneumococcal pneumonia and influenza virus vaccinations and submit these services as electronic media claims, paper claims, or using the roster billing method. This generally takes place in a mass immunization setting, such as, a public health center, pharmacy, or mall but may include a physician office setting. A facility that provides comprehensive rehabilitation services under the supervision of a physician to inpatients with physical disabilities. Services include physical therapy, occupational therapy, speech therapy, speech pathology, social or psychological services, and orthotics and prosthetics services. 60 Revision 4/1/17 Common Billing Information ____________________________________________________ Place of Service 62 63-64 65 66-70 Place of Service Name Comprehensive Outpatient Rehabilitation Facility Unassigned End-Stage Renal Disease Treatment Facility Unassigned 71 Public Health Clinic 72 Rural Health Clinic 73-80 Unassigned 81 Independent Laboratory 82-98 99 6.5 Unassigned Other Place of Service Place of Service Description A facility that provides comprehensive rehabilitation services to outpatients with physical disabilities. Services include physical therapy, occupational therapy, and speech pathology services. N/A A facility other that a hospital, which provides dialysis treatment, maintenance, and /or training to patients or caregivers on an ambulatory or home-care basis. N/A A facility maintained by either State or local health departments that provide ambulatory primary medical care under the general direction of a physician. A certified facility, which is located in a rural medically, underserved area that provides ambulatory primary medical care under the general direction of a physician. N/A A laboratory certified to perform diagnostic and/or clinical tests independent of an institution or a physician’s office. N/A Other place of service not listed above. Medicare Crossovers Medicaid processes claims for Medicare/Medicaid services when provided to a Medicaid eligible client. 6.5.1 General Information Dually eligible clients are clients that are eligible for Medicare and Medicaid. Providers may verify Medicare and Medicaid eligibility through the IVR (2.1, Quick Reference). Providers must accept assignment of claims for dually eligible clients. Be sure Wyoming Medicaid has record of all applicable NPIs under which the provider is submitting to Medicare to facilitate the electronic crossover process. Medicaid reimburses the lesser of the assigned coinsurance and deductible amounts or the difference between the Medicaid allowable and the Medicare paid amount for dually eligible clients as indicated on the Medicare (Explanation of Medicare Benefits) EOMB. Ch. 6 Index 61 Revision 4/1/17 Common Billing Information ____________________________________________________ o Wyoming Medicaid’s payment is payment in full. The client is not responsible for any amount left over, even if assigned to coinsurance or deductible by Medicare. 6.5.2 Billing Information Medicare is primary to Medicaid and must be billed first. Direct Medicare claims processing questions to the Medicare carrier. When posting the Medicare payment, the EOMB (Explanation of Medicare Benefits) may state that the claim has been forwarded to Medicaid. No further action is required, it has automatically been submitted. Medicare transmits electronic claims to Medicaid daily. Medicare transmits all lines on a claim with any Medicare paid claim – If one (1) line pays, and three (3) others are denied by Medicare, all four (4) lines will be transmitted to Wyoming Medicaid. The time limit for filing Medicare crossover claims to Medicaid is 12-months from the date of service or six (6) months from the date of the Medicare payment, whichever is later. If payment is not received from Medicaid after 45-days of the Medicare payment, submit a claim to Medicaid and include the COB (Coordination of Benefits) information in the electronic claim. The line items on the claim being submitted to Medicaid must be exactly the same as the claim submitted to Medicare, except when Medicare denies then the claim must conform to Medicaid policy. If a paper claim is being submitted, the EOMB must be attached. If the Medicare policy is a replacement/advantage or supplement, this information must be noted (it can be hand written) on the EOMB. NOTE: Ch. 6 Index Do not resubmit a claim for coinsurance or deductible amounts unless the provider has waited 45-days from Medicare’s payment date. A provider’s claims may be returned if submitted without waiting the 45-days after the Medicare payment date. 62 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.6 Examples of Billing 6.6.1 Client has Medicaid Coverage Only or Medicaid and Medicare Coverage NOTE: Ch. 6 Index When client has dual coverage, (Medicaid and Medicare) attach the EOMB to the claim. 63 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.6.2 Client has Medicaid and Third Party Liability (TPL) or Client has Medicaid, Medicare and TPL NOTE: Ch. 6 Index If the client has both Medicare and TPL in addition to Medicaid, attach the TPL EOB and the Medicare EOMB to the claim. If the client has TPL and Medicaid but no Medicare, attach the TPL EOB to the claim. 64 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.7 National Drug Code (NDC) Billing Requirement Effective for dates of service on and after March 1, 2008 Medicaid will require providers to include National Drug Codes (NDCs) on professional and institutional claims when certain drug-related procedure codes are billed. This policy is mandated by the Federal Deficit Reduction Act (DRA) of 2005, which requires state Medicaid programs to collect rebates from drug manufacturers when their products are administered in an office, clinic, hospital or other outpatient setting. The NDC is a unique 11-digit identifier assigned to a drug product by the labeler/manufacturer under Federal Drug Administration (FDA) regulations. It is comprised of three (3) segments configured in a 5-4-2 format. 6 5 2 9 3 - 0 0 0 1 - 0 1 Labeler Code Product Code (5 Digits) (4 Digits) Package Code (2 Digits) Labeler Code – Five (5) digit number assigned by the Food and Drug Administration (FDA) to uniquely identify each firm that manufactures, repacks, or distributes drug products. Product Code – Four (4) digit number that identifies the specific drug, strength and dosage form. Package Code – Two (2) digit number that identifies the package size. Converting 10-Digit NDC’s to 11-Digits 6.7.1 Many NDCs are displayed on drug products using a ten (10) digit format. However, to meet the requirements of the new policy, NDCs must be billed to Medicaid using the 11-digits FDA standard. Converting an NDC from ten (10) to 11-digits requires the strategic placement of a zero (0). The following table shows three (3) common ten (10) digit NDC formats converted to 11-digits. Converting 10-Digit NDCs to 11-Digits 10-Digit Format Sample 10-Digit NDC Required 11-Digit Format Sample 10-Digit NDC Converted to 11-Digits 9999-9999-99 (4-4-2) 0002-7597-01 Zyprexa 10mg vial 09999-9999-99 (5-4-2) 00002-7597-01 99999-999-99 (5-3-2) 50242-040-62 Xolair 150mg vial 99999-0999-99 (5-4-2) 50242-0040-62 99999-9999-9 (5-4-1) 60575-4112-1 Synagis 50mg vial 99999-9999-09 (5-4-2) 60575-4112-01 Ch. 6 Index 65 Revision 4/1/17 Common Billing Information ____________________________________________________ NOTE: 6.7.2 Hyphens are used solely to illustrate the various ten (10) and 11 digit formats. Do not use hyphens when billing NDCs. Documenting and Billing the Appropriate NDC A drug may have multiple manufacturers so it is vital to use the NDC of the administered drug and not another manufacturer’s product, even if the chemical name is the same. It is important that providers develop a process to capture the NDC when the drug is administered, before the packaging is thrown away. It is not permissible to bill Medicaid with any NDC other than the one (1) administered. Providers should not pre-program their billing systems to automatically utilize a certain NDC for a procedure code that does not accurately reflect the product that was administered to the client. Clinical documentation must record the NDC from the actual product, not just from the packaging, as these may not match. Documentation must also record the lot number and expiration date for future reference in the event of a health or safety product recall. Ch. 6 Index 66 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.7.3 Procedure Code/NDC Combinations The list of rebateable NDCs Medicaid posts to its website will also present providers a way to validate procedure code/NDC combinations. The table below illustrates a few sample entries from the list. NDC Procedure Code 584680040-01 J0180 584680041-01 J0180 584681060-01 J0205 005178905-01 J0210 Procedure Description NDC Label Rebateable Rebate Start Date Rebate End Date Y 01/01/1991 99/99/9999 Y 01/01/1991 99/99/9999 Y 01/01/1991 99/99/9999 Y 10/01/1991 99/99/9999 Injection, Fabrazyme (PF) Agalsidase 35 MG Beta, 1 MG Injection, Fabrazyme (PF) Agalsidase 5 MG Beta, 1 MG Injection, Ceredase 80 Alglucerase, U/ML Per 10 Injection, Methyldopate Methyldopa HCL (S.D.V.) 50 te HCL The first two (2) entries show NDCs 58468-0040-01 and 58468-0041-01 can only be paired with one (1) procedure code, J0180. These are the only valid procedure code / NDC combinations when billing Agalsidase. Pairing either NDC with a different procedure code OR pairing the procedure code with a different NDC would create an invalid combination. Procedure code / NDC combinations deemed invalid according to the list will be denied. 6.7.4 Billing Requirements The requirement to report NDCs on professional and institutional claims is meant to supplement procedure code billing, not replace it. Providers are still required to include applicable procedure code information such as dates of service, CPT/HCPCS code, modifier(s), charges and units. 6.7.5 Submitting One NDC per Procedure Code If one (1) NDC is to be submitted for a procedure code, the procedure code, procedure quantity and NDC must be reported. No modifier is required. Procedure Code 90378 Ch. 6 Index Modifier Procedure Quantity 2 67 NDC 60574-4111-01 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.7.6 Submitting Multiple NDCs per Procedure Code If two (2) or more NDCs are to be submitted for a procedure code, the procedure code must be repeated on separate lines for each unique NDC. For example, if a provider administers 150 mg of Synagis, a 50 mg vial and a 100 mg vial would be used. Although the vials have separate NDCs, the drug has one (1) procedure code, 90378. So, the procedure code would be reported twice on the claim, but paired with different NDCs. Procedure Code 90378 90378 Modifier KP KQ Procedure Quantity 2 1 NDC 60574-4111-01 60574-4112-01 On the first (1st) line, the procedure code, procedure quantity, and NDC are reported with a KP modifier (first drug of a multi-drug). On the second line, the procedure code, procedure quantity and NDC are reported with a KQ modifier (second/subsequent drug of a multi-drug). NOTE: 6.7.7 When reporting more than two (2) NDCs per procedure code, the KQ modifier is also used on the subsequent lines. Medicare Crossover Claims Because Medicaid pays Medicare coinsurance and deductible for dual-eligible clients, the NDC will also be required on Medicare crossover claims for all applicable procedure codes. Medicaid has verified that NDC information reported on claims submitted to Medicare will be included in the automated crossover claim feed to Medicaid. Crossover claim lines that are missing a required NDC will be denied. 6.7.8 CMS-1500 02-12 Billing Instructions To report a procedure code with a NDC on the CMS-1500 02-12 claim form, enter the following NDC information into the shaded portion of field 24A: NDC qualifier of N4 [Required] NDC 11-digit numeric code [Required] Do not enter a space between the N4 qualifier and the NDC. Do not enter hyphens or spaces within the NDC. CMS-1500 02-12 – One (1) NDC per Procedure Code: Ch. 6 Index 68 Revision 4/1/17 Common Billing Information ____________________________________________________ CMS-1500 02-12 – Two (2) NDCs per Procedure Code: NOTE: 6.8 Medicaid’s instructions follow the National Uniform Claim Committee’s (NUCC) recommended guidelines for reporting the NDC on the CMS1500 02-12 claim form. Provider claims that do not adhere to these guidelines will be returned unprocessed. Cap Limits Medicaid clients 21 years of age and older are subject to service cap limits on the number of office/outpatient hospital visits and behavioral health visits. Medicaid clients of any age are subject to service cap limits on the number of physical/occupational/speech therapy visits, chiropractic visits, dietician visits and emergency dental visits they receive. OFFICE AND OUTPATIENT HOSPITAL VISITS Codes Limits Procedure Codes: 99281-99285 99201-99215 Does not apply to: 12 combined visits per calendar year Revenue Codes: 0450-0459 0510-0519 NOTE: Ch. 6 Index Clients Under Age 21 Emergency Visits Family Planning Services Medicare Crossovers Ancillary services (e.g., lab, x-ray, etc.) provided during an office/outpatient hospital visit that exceeded the cap limit will still be reimbursed. 69 Revision 4/1/17 Common Billing Information ____________________________________________________ PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, BEHAVIORAL HEALTH VISITS, CHIROPRACTIC VISITS AND DIETICIAN Codes Procedure codes: 90785; 90792; 9083290834; 90836-90839; 90845-90849; 90853; 90857;92507-92508; 92526; 96101-96125; 97010-97039; 9711097546, 97802-97804, 98940-98942; (all modalities on same date of service count as 1 visit) HCPCS Level II codes: G9012; H0005-H0006; H0031; H0034; H0047; H2010; H2014; H2015; H2017; H2019; H2021; T1007; T1012; T1017 (all modalities on same date of service count as 1 visit) Revenue codes: 0420,0421, 0422,0 424, 0430, 0431, 0432, 0434, 0439, 0440, 0441, 0442, 0444, and 0449 (each unit counts as 1 visit) Limits Does not apply to: Medicare Crossovers 20 physical therapy visits per calendar year 20 occupational therapy visits per calendar year 20 speech therapy visits per calendar year 20 behavioral health visits per calendar year (21 and over only) 20 chiropractic visits per calendar year 20 dietician visits per calendar year If a client has exceeded the Medicaid limits on office/outpatient hospital visits, physical/occupational/speech therapy visits, behavioral health visits, chiropractic visits, or dietitian visits the provider may bill him/her or request the cap limit be waived. 6.8.1 Cap Limit Waiver Physicians, nurse practitioners, physical, occupational and speech therapists, psychiatrist, psychologists, licensed mental health professionals such as licensed professional counselors, licensed marriage and family therapist, licensed certified social workers and licensed addiction therapists, community mental health or substance abuse treatment centers, chiropractors and dieticians may request a waiver of a cap limit once a limit has been reached. Ch. 6 Index 70 Revision 4/1/17 Common Billing Information ____________________________________________________ Cap limit waiver requests must be submitted on the Cap Limit Waiver Request form and cite specific medical necessity. Below is the Cap Limit Waiver Request form for office visits, therapies (PT, OT, ST and Chiropractic services), dietician visits and Behavioral Health visits (6.9.2 Cap Limit Waiver Request Form). The form must be mailed to: Wyoming Medicaid Attn: Medical Policy PO Box 667 Cheyenne, WY 82003-0667 If granted, a cap limit waiver is valid for one (1) calendar year. For additional information, contact Medical Policy (2.1, Quick Reference). If a cap limit waiver request is denied, the provider may request reconsideration by mail by providing additional supporting documentation to include but not limited to a detailed letter of explanation as to why you feel the denial is incorrect, additional medical records and/or testing results. This request must be in accordance with Medicaid rules. 6.8.2 Cap Limit Waiver Request Form NOTE: Ch. 6 Index Click image above to be taken to a printable version of this form 71 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.8.3 Cap Limit Waiver Request Form Instructions Field Action Pay to (Group) NPI Complete with the ten digit NPI number for the Pay to/Group Provider Pay to (Group) Name Complete with the name of the Pay to/Group Provider Treating/Rendering NPI Complete with the ten digit NPI number for the treating provider Treating/Rendering Name Complete with the name of the treating provider Client ID Complete with the client’s Wyoming Medicaid ID number Client Name Complete with the client’s full name Client Age Complete with the client’s age at the time of the request Cap Limit Year Complete with the requested calendar year for the cap limit waiver Cap Limit Begin/End Date Complete with the dates the cap limit waiver will need to begin and when it will end Cap Limit Type Check the appropriate box for which type cap limit waiver you are requesting Date of Onset Condition Complete with the date the onset condition began Diagnosis Code Complete with the diagnosis codes – up to four are allowed Ordering Provider Name & NPI Complete with the Name and NPI number for the ordering provider – this section is required for Speech, Occupational or Physical Therapy Describe injury, illness, surgery or triggering event that initiated the need for services Complete with what caused the acute condition (i.e. post-surgery, personal injury, auto accident, etc.) Describe acute condition requiring rehabilitative services A detailed explanation as to the diagnosis and rehabilitative need for services for acute conditions only. Indicate why the client has exceeded their CAP limit. For Behavioral Health Cap Limit Waiver Request, ensure to include last 5 progress reports and treatment plan. Describe anticipated rehabilitative progress and length of additional treatment Describe the rehabilitative progress anticipated and the length needed for additional treatment. For physical, occupational, or speech therapy Cap Limit Waiver Requests, ensure you attach a copy of the practitioner’s order. Treating provider signature and date The provider providing the services will need to sign and date the Cap Limit Waiver Request Form Ch. 6 Index 72 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.8.4 Cap Limit Additional Information for Clients Under the Age of 21 In addition to the completion of the Cap Limit Waiver Request Form, the Additional Information sheet must be completed for clients under the age of 21. Ch. 6 Index 73 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.8.5 Cap Limit Additional Information Instructions Cap Limit Additional Information For Children who are school age: Field Action Is this child on IEP? Indicate whether or not the child is on an Individualized Education Program (IEP) What services is the child receiving through school system? Describe the services the child is receiving through the school system under the IEP How are the services you are provider distinct from the services being provided through the school system and how are you avoiding conflict with the services being provided? Describe how the services you are providing to the client are different from the services that are being provided through the school system and how you are avoiding conflict with those services For kids who are younger than school age Has this child been Indicate whether or not this child has been evaluated at a Child Development Center evaluated at a Child (CDC) Development Center? What services is the child receiving through the CDC? Describe the services the child is receiving through the Child Development Center How are the services you are providing distinct from the services being provided through the CDC and how are you avoiding conflict with the services being provided? Describe the services you are providing and how they are distinct from the services that are being provided through the Child Development Center and how you are avoiding conflict with those services being provided through the CDC Ch. 6 Index 74 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.9 Reimbursement Methodologies Medicaid reimbursement for covered services is based on a variety of payment methodologies depending on the service provided. Medicaid fee schedule By report pricing Billed charges Invoice charges Negotiated rates Per diem RBRVS (Resource Based Relative Value Scale) 6.10 Usual and Customary Charges Charges for services submitted to Medicaid must be made in accordance with an individual provider’s usual and customary charges to the general public unless: The provider has entered into an agreement with the Medicaid Program to provide services at a negotiated rate; or The provider has been directed by the Medicaid Program to submit charges at a Medicaid-specified rate. 6.10.1 Invoice Charges Invoice must be dated within 12-months prior to the date of service being Ch. 6 Index billed – if the invoice is older, a letter must be included explaining the age of the invoice (i.e. product purchased in large quantity previously, and is still in stock) All discounts will be taken on the invoice. The discounted pricing or codes cannot be marked out. A packing slip, price quote, purchase order, delivery ticket, etc. may be used only if the provider no longer has access to the invoice, and is unable to obtain a replacement from the supplier/manufacturer, and a letter with explanation is included. Items must be clearly marked. (i.e. how many calories are in a can of formula, items in a case, milligrams, ounces, etc.) 75 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.11 Co-Payment Schedule $2.45 Co-Payment Schedule Procedure and Revenue Code(s) 99201 – 99215 99341 -99350 92002, 92004, 92014 90804 – 90815 Description Exceptions Office Visits only when the place of service code is 11 Home Visits Eye Examinations Medical psychotherapy – copayment only applies when the place of service code is 11 Co-payment requirements do not apply to: Clients under age 21 Nursing Facility Residents Pregnant Women Family planning services Emergency services Hospice services Medicare Crossovers Members of a Federally recognized tribe 6.12 How to Bill for Newborns When a mother is eligible for Medicaid, at the time the baby is born, the newborn is automatically eligible for Medicaid for one (1) year. However, the WDH Customer Service Center must be notified of the newborn’s name, gender, and date of birth, mom’s name and Medicaid number for a Medicaid ID Card to be issued. This information can be faxed, emailed, or mailed to the WDH Customer Service Center on letterhead from the hospital where the baby was born or reported by the parent of the baby. A provider will need to have the newborn client ID in order to bill newborn claims. 6.13 Prior Authorization Medicaid requires prior authorization (PA) on selected services and equipment. Approval of a PA is never a guarantee of payment. A provider should not render services until a client’s eligibility has been verified and a PA has been approved (if a PA is required). Services rendered without obtaining a PA (when a PA is required) may not be reimbursed. Selected services and equipment requiring prior authorization include, but are not limited to, the following – use in conjunction with the Medicaid Fee Schedule to verify what needs PA: Ch. 6 Index 76 Revision 4/1/17 Common Billing Information ____________________________________________________ Agency Name Division of Healthcare Financing (DHCF) Dental Services Behavioral Health Division Goold Health Systems Inc. (GHS) Phone Services Requiring PA Contact case manager Case manager will contact the DHCF (888)863-5806 Reference Dental Manual for details Contact case manager Case manager will contact the Behavioral Health Division (877)207-1126 Pharmacy (888)545-1710 Advanced Radiology, Cardiology and HealthHelp Radiation Therapy Option 2 Magellan Assisted Living Facility (ALF) Waiver Long Term Care (LTC) Waiver Out-of-State Home Health Out-of-State Placement for LTC Facilities Malocclusion (PA) Implants & fixed bridges (PA) Maxillofacial Surgeries (PA) Acquired Brain Injury (ABI) Waiver Services Developmentally Disabled Adult Waiver Services Developmentally Disabled Children Waiver Services Children’s Mental Health Waiver (855)883-8740 Services Hospice Services: Limited to clients residing in a nursing home Medical Policy Qualis Health (DMEPOS) WYhealth (Utilization and Care Management) 6.13.1 Ch. 6 Index Out-of-State Home Health Surgeries Requiring PA (not listed in (800)251-1268 Option 1, 1, 4, 3 this table) Tysabri IV Infusion Treatment Contact Lenses Certain Eyeglass Lenses Scleral Cover Shell Durable Medical Equipment (DME) Prosthetic and Orthotic Supplies (POS) Home Health (800)783-8606 Acute Psych Extended Psych Extraordinary Care Gastric Bypass Inpatient Rehabilitation PRTF – Psychiatric Residential Treatment Facility Transplants Vagus Nerve Stimulator (888)545-1710 Requesting Prior Authorization from Medical Policy 77 Revision 4/1/17 Common Billing Information ____________________________________________________ This section only applies to providers requesting PA for out-of-state Home Health, certain surgeries and hospice services (limited to clients residing in a nursing home). For all other types of PA requests, contact the appropriate authorizing agencies listed above for their written PA procedures. Providers have three (3) ways to request and receive a PA: Medicaid Prior Authorization Form (6.14.1.1, Medicaid Prior Authorization Form). A hardcopy form for requesting a PA by mail or fax. For a copy of the form and instructions on how to complete it, refer to the following section. X12N 278 Prior Authorization Request and Response. A standard electronic file format used to transmit PA requests and receive responses. For additional information, refer to Chapter 8, Electronic Data Interchange (EDI) and Chapter 9, Wyoming Specific HIPAA 5010 Electronic Specifications; or Web-Based Entry (Limited to Medical Policy PA requests). A web-based option for entering PA requests and receiving responses via Medicaid Secured Provider Web Portal. For direction on entering a PA request through the Secured Provider Web Portal, view the Web Portal Tutorial found on the website. (2.1, Quick Reference). For additional information, refer to Chapter 8, Electronic Data Interchange (EDI) and Chapter 9, Wyoming Specific HIPAA 5010 Electronic Specifications. Ch. 6 Index 78 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.13.1.1 NOTE: 6.13.1.2 Medicaid Prior Authorization Form Click image above to be taken to a printable version of this form. Instructions for Completing the Medicaid Prior Authorization Form Completing the Medicaid Prior Authorization Form for medical services *Denotes Required Field Field Number 1 2 3* 4* 5* 6* 7* 8 Ch. 6 Index NOTE: Is this an Add, Modify, or Cancel request? Title Action Date of Birth Enter MMDDYY of client’s date of birth. Age Enter client’s age. Enter the client’s ten (10) digit Medicaid ID Medicaid ID Number number. Enter Last Name, First Name and Middle Patient Name Initial exactly as it appears on the Medicaid ID card. Pay-To Provider NPI Enter the Pay to Provider NPI Numbers. # Pay To Provider Enter the Pay To Provider Taxonomy. Taxonomy Pay To Provider Enter the Pay To Provider Name. Name Street Address Enter the Pay To Provider Street Address. 79 Revision 4/1/17 Common Billing Information ____________________________________________________ Completing the Medicaid Prior Authorization Form for medical services *Denotes Required Field Field Number 9 10* 11* 12* 13* 14* 15* 16* 17* 18* 19* 20 21* 22 NOTE: Ch. 6 Index NOTE: Is this an Add, Modify, or Cancel request? Title Action Enter the Pay To Provider City, State and Zip City, State, Zip Code Code. Telephone – Contact Enter phone number of the contact person Person for this prior authorization. Enter the name of the person that can be Contact Name contacted regarding this Prior Authorization. Enter to the best of the providers ability, Proposed Dates of what dates of service the provider is looking service for. It can be one (1) day or a date range. Enter the service that the provider is Service Description requesting. Procedure Code for the service(s) being Procedure Code requested. Modifier needed to bill the procedure on the Modifier(s) claim – If no modifiers needed – put N/A. Unit(s) Enter number of each service requested. Enter dollar amount times the unit(s) for Estimated Cost each service requested. Treating Provider Enter the Treating Provider NPI Number – NPI Number Needs to be a Wyoming Medicaid Provider. Please attach all documentation to support medical necessity. Applicable documentation must be supplied in Supporting sufficient detail to satisfy the medical Documentation necessity for the prescribed service. Additional documentation may be attached when necessary. This is the entry of changes that are needed by Modifications the provider from the original request. The form needs to be signed and dated by Signature the entity requesting the prior authorization of services. If called in for a verbal authorization, put the Pending Authorization name of the person giving the PA number and date. The Prior Authorization Request Form must match the lines on the claim that are being billed. 80 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.13.2 Requesting an Emergency Prior Authorization In the case of a medical emergency, providers should contact Medical Policy by telephone, after business hours and on weekends, leave a message. Medical Policy will provide a pending PA number until a formal request is submitted. The formal request must be submitted within 30-days of receiving the pending PA number and must include all documentation required. NOTE: 6.13.2.1 Contact the other appropriate authorizing agencies for pending/emergency PA procedures (6.14, Prior Authorization). their Prior Authorization Approval Once a PA is approved, an approval letter (sample approval letter below) is mailed that includes the PA number. The PA number must be entered in box 23 of the CMS1500 02-12 claim form. For placement in an electronic X12N 837 Professional Claim, consult the Electronic Data Interchange Technical Report Type 3 (TR3). The TR3 can be accessed at http://www.wpc-edi.com. Ch. 6 Index 81 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.13.2.2 Sample PA Approval Letter 02/26/15 SAMPLE PROVIDER OF WYOMING LTC WAIVER SERVICES 1234 SAMPLE STREET SAMPLE WY 82001 MEDICAID PRIOR AUTHORIZATION NOTICE Client : SAMPLE CLIENT Client ID: 0000062141 PA-NUMBER 0012900194 Waiver Case Manager : ***PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY*** The prior authorization request submitted on behalf of Sample Client has been determined as follows: 01/01/15-01/31/15 T2041 – SUPPORTS BROKERAGE, SELF DIRECTED, 12 MIN APPROVED APPR UNITS: 300 UNIT PRICE $ 3.32 USED UNITS: 202 02/01/15-02/28/15 T2041 – SUPPORTS BROKERAGE, SELF DRIECTED, 15 MIN APPROVED APPR UNITS: 300 UNIT PRICE $ 3.32 USED UNITS: 0 CODE EXPLANATIONS: NO DENIAL REASON PROVIDED COMMENT: A8200RB1 NOTE: PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY. PAYMENT IS SUBJECT TO THE CLIENT’S ELIGIBILITY AND MEDICAID BENEFIT LIMITATIONS. VERIFY ELIGIBILITY BEFORE RENDERING SERVICES PA-NUMBER 0012900194 A8200RB1 NOTE: Ch. 6 Index For lines that are approved, the corresponding item may be purchased or delivered, or service may be rendered. 82 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.13.2.3 Prior Authorization Denial If a PA request is denied, the provider may request reconsideration to the appropriate agency. This request must be in accordance with Medicaid rules. 6.13.2.4 Sample Prior Authorization Denial Letter 01/19/15 MEDICAID PRIOR AUTHORIZATION NOTICE SAMPLE PROVIDER OF WYOMING 1234 SAMPLE STREET SAMPLE WY 82001 Client: SAMPLE CLIENT Client ID: 0000062141 PA-Number: 00198000001 ***PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY*** The prior authorization request submitted on behalf of Sample Client has been determined as follows: 01/18/10-01/18/11 V2715 – PRISM, PER LENS APPR UNITS: 0 USED UNITS: 0 DENIED CODE EXPLANATIONS: 800 SERVICE NOT COVERED BY WYOMING MEDICAID COMMENT: DOES NOT FALL WITHIN AGE GUIDELINES FOR PROC CODE NOTE: PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY. PAYMENT IS SUBJECT TO THE CLIENT’S ELIGIBILITY AND MEDICAID BENEFIT LIMITATIONS. VERIFY ELIGIBILITY BEFORE RENDERING SERVICES. PA-Number: 00198000001 A1500RB2 NOTE: Ch. 6 Index For lines that are denied, additional information may be needed before the item or service can be reconsidered for approval. It is imperative this information be supplied to the appropriate agency. 83 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.13.2.5 Prior Authorization Pending If a PA request is in a pending status, it was likely the result of an emergency request made over the phone to Medical Policy. A claim cannot be billed using a PA number from a pending request (2.1, Quick Reference). 6.13.2.6 Sample Prior Authorization Pending 10/01/15 SAMPLE PROVIDER OF WYOMING 1234 SAMPLE STREET SAMPLE WY 82001 MEDICAID PRIOR AUTHORIZATION NOTICE Client: SAMPLE CLIENT Client ID: 0000062141 *** PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY*** The prior authorization request submitted on behalf of SAMPLE CLIENT has been determined as follows: 01/18/15-01/18/16 V2715 – PRISM, PER LENS APPR UNITS: 2 UNIT PRICE:$ 9.32 USED UNITS: 0 PENDING CODE EXPLANATIONS: NO DENIAL REASON PROVIDED COMMENT: RECEIVED GLASSES LESS THAN A YEAR AGO NEED DOCUMENTATION SAYING WILL REUSE OLD FRAMES NOTE: PRIOR AUTHORIZATION APPROVAL DOES NOT GUARANTEE ELIGIBILITY. PAYMENT IS SUBJECT TO THE RECIPIENT’S ELIGIBILITY AND MEDICAID BENEFIT LIMITATIONS. VERIFY ELIGIBILITY BEFORE RENDERING SERVICES. PA-Number: 00198000002 A1500RB2 Ch. 6 Index 84 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.14 Order vs Delivery Date All procedures that involve delivering an item to the client can only be billed to Medicaid on the date the item is delivered to the client. This includes glasses, DME products/supplies, dental appliances, etc. The provider is responsible for billing these procedures only on the delivery date. Wyoming Medicaid will allow a provider to bill using the order date only if one of the following conditions are present: Client is not eligible on the delivery date but was eligible on the order date Client does not return to the office for the delivery of the product A provider may use the order date as the date of service only if they have obtained a signed exception form from the State. To obtain this authorization, follow the steps below. Print the “Order vs Delivery Date Exception Form” (link to form below) Complete the form and fax or mail the form to the address at the bottom of the form Once the form is signed by the State, it will be returned to the provider and must be a part of the client’s permanent clinical record The provider may then bill the claim using the order date as the date of service NOTE: If an audit of clinical records is performed, and it is found that the provider billed on the order date but does not have a signed “Order vs Delivery Date Exception Form” for the client and the DOS, the money paid will be recovered. Ch. 6 Index 85 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.14.1 Order vs Delivery Date Exception Form NOTE: Click image above to be taken to a printable version of this form 6.15 Submitting Attachments for Electronic Claims Providers may either upload their documents electronically or complete the Attachment Cover Sheet and mail their documents. Steps for submitting electronic attachments: 1. The fiscal agent has created a process that allows providers to submit electronic attachments for electronic claims. Providers need only follow these steps: Ch. 6 Index 86 Revision 4/1/17 Common Billing Information ____________________________________________________ NOTE: Mark the attachment indicator on the electronic claim. For more information on the attachment indicator, consult the provider software vendor or clearinghouse, or the X12N 837 Professional Electronic Data Interchange Technical Report Type 3 (TR3). The TR3 can be accessed at http://www.wpcedi.com. Log onto Secured Provider Web Portal. Under the submissions menu select Electronic Attachments. Complete required information – Information must match the claim as submitted i.e., DOS, client information, provider information, and the name of the attachment must be identical to what was submitted in the electronic file (with no spaces). Select Browse Navigate to the location of the electronic attachment on the provider’s computer. Click Upload. For support and additional information refer to Chapter 8 and Chapter 9 or contact EDI Services (2.1, Quick Reference). One (1) attachment per claim, providers may not attach one (1) document to many claims. Also, if the attachment is not received within 30-days of the electronic claim submission, the claim will deny and it will be necessary to resubmit it with the proper attachment. Steps for submitting paper attachments 1. The fiscal agent has created a process that allows providers to submit paper attachments for electronic claims. Providers need only follow these two (2) simple steps: Mark the attachment indicator on the electronic claim and indicate by mail as the submission method. For more information on the attachment indicator, consult the provider software vendor or clearinghouse, or the X12N 837 Professional Electronic Data Interchange Technical Report Type 3 (TR3). The TR3 can be accessed at http://www.wpcedi.com.The data entered on the form must match the claim exactly in DOS, client information, provider information, etc. Complete Attachment Cover Sheet (6.15.1, Attachment Cover Sheet) and mail it with the attachment to Claims (2.1, Quick Reference). NOTE: Ch. 6 Index Both steps must be followed; otherwise, the fiscal agent will not be able to join the electronic claim and paper attachment, and the claim will deny. Also, if the paper attachment is not received within 30-days of the 87 Revision 4/1/17 Common Billing Information ____________________________________________________ electronic claim submission, the claim will deny and it will be necessary to resubmit it with the proper attachment. 6.15.1 Attachment Cover Sheet NOTE: Click image above to be taken to a printable version of this form. 6.16 Sterilization, Hysterectomy and Abortion Consent Forms When providing services to a Medicaid client, certain procedures or conditions require a consent form be completed and attached to the claim. This section describes the following forms and explains how to prepare them: Sterilization Consent Form Hysterectomy Consent Form Abortion Certification Form 6.16.1 Sterilization Consent Form and Guidelines Federal regulations require that clients give written consent prior to sterilization; otherwise, Medicaid cannot reimburse for the procedure. Ch. 6 Index 88 Revision 4/1/17 Common Billing Information ____________________________________________________ The Sterilization Consent Form may be obtained from the fiscal agent or copied from this manual. As mandated by Federal regulations, the consent form must be attached to all claims for sterilization-related procedures. All sterilization claims must be processed according to the following Federal guidelines: FEDERAL GUIDELINES The waiting period between consent and sterilization must not exceed 180 days and must be at least 30 days, except in cases of premature delivery and emergency abdominal surgery. The day the client signs the consent form and the surgical dates are not included in the 30-day requirement. For example, a client signs the consent form on July 1. To determine when the waiting period is completed, count 30days beginning on July 2. The last day of the waiting period would be July 31; therefore, surgery may be performed on August 1. In the event of premature delivery, the consent form must be completed and signed by the client at least 72-hours prior to the sterilization, and at least 30-days prior to the expected date of delivery. In the event of emergency abdominal surgery, the client must complete and sign the consent form at least 72-hours prior to sterilization. The consent form supplied by the surgeon must be attached to every claim for sterilization related procedures; i.e., ambulatory surgical center clinic, physician, anesthesiologist, inpatient or outpatient hospital. Any claim for a sterilization related procedure which does not have a signed and dated, valid consent form will be denied. All blanks on the consent form must be completed with the requested information. The consent form must be signed and dated by the client, the interpreter (if one is necessary), the person who obtained the consent, and the physician who will perform the sterilization. The physician statement on the consent form must be signed and dated by the physician who will perform the sterilization on the date of the sterilization or after the sterilization procedure was performed. The date on the sterilization claim form must be identical to the date and type of operation given in the physician’s statement. Ch. 6 Index 89 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.16.1.1 Sterilization Consent Form NOTE: 6.16.1.2 Click image above to be taken to a printable version of this form. Instructions for Completing the Sterilization Consent Form Important tips for completing the Sterilization Consent Form Print legibly to avoid denials – The entire form must be legible. The originating practitioner has ownership of this form and must supply 6.16.2 correct, accurate copies to all involved billing parties. Fields 7, 8 and 15, 16 must be completed prior to the procedure. All fields may be corrected however corrections must be made with one (1) line through the error and must be initialed. The person that signed the line is the only person that can make the alteration. “Whiteout” will not be accepted when making corrections. Every effort should be taken to complete the form correctly without any changes. Hysterectomy Acknowledgment of Consent The Hysterectomy Acknowledgment of Consent Form must accompany all claims for hysterectomy-related services; otherwise, Medicaid will not cover the services. The Ch. 6 Index 90 Revision 4/1/17 Common Billing Information ____________________________________________________ originating physician is required to supply other billing providers (e.g., hospital, surgeon, anesthesiologist, etc.) with a copy of the completed consent form. NOTE: Section Instructions for attaching documents to claims refer to Section 6.15. Field # Action 1 9 10 11 12 Enter the name of the physician or the name of the clinic from which the client received sterilization information. Enter the type of operation (no abbreviations) Enter the client’s date of birth (MM/DD/YY). Client must be at least 21 years Enter the client’s name Enter the name of the physician performing the surgery Enter the name of the type of operation (no abbreviations) The client to be sterilized signs here The client dates signature here Check one (1) box appropriate for client. This item is requested but NOT required. Enter the name of the language the information was translated to Interpreter signs here Interpreter dates signature here 13 Enter clients name 14 15 16 Enter the name of the operation (no abbreviations) The person obtaining consent from the client signs here The person obtaining consent from the client dates signature here The person obtaining consent from the client enters the name of the facility where the person obtaining consent is employed. The facility name must be completely spelled out (no abbreviations) The person obtaining consent from the client enters the complete address of the facility in #17 above. Address must be complete, including state and zip code 2 3 Consent to Sterilization Interpreter’s Statement Statement of person obtaining consent Statement of person obtaining consent Physician’s Statement Physician’s Statement 4 5 6 7 8 17 18 19 Enter the client’s name 20 21 Enter the date of sterilization operation Enter type of operation (no abbreviations) Check applicable box: If premature delivery is checked, the provider must write in the expected date of delivery here. If emergency abdominal surgery is checked, describe circumstances here. Physician performing the sterilization signs here Physician performing the sterilization dates signature here 22 23 24 Ch. 6 Index 91 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.16.2.1 Instructions for Completing the Hysterectomy Acknowledgment of Consent Form Section Part A Part B Part C Field # 1 Enter the name of the physician performing the surgery. 2 Enter the narrative diagnosis for the client’s condition. 3 The client receiving the surgery signs here and dates. 4 The person explaining the surgery signs here and dates. 5 Enter the date and the physician’s name that performed the hysterectomy. 6 Enter the narrative diagnosis for the client’s condition. 7 The client receiving the surgery signs here and dates. 8 The person explaining the surgery signs here and dates. 9 Enter the narrative diagnosis for the client’s condition. Check applicable box: If other reason for sterility is checked, the provider must write what was done. If previous tubal is checked, the provider must enter the date of the tubal. If emergency situation is checked, the provider must enter the description. 10 11 Ch. 6 Index Action The physician who performed the hysterectomy signs here and dates. 92 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.16.2.2 NOTE: 6.16.3 Hysterectomy Acknowledgment Consent Form Click image above to be taken to a printable version of this form. Abortion Certification Guidelines The Abortion Certification Form must accompany claims for abortion-related services; otherwise, Medicaid will not cover the services. This requirement includes, but is not limited to, claims from the attending physician, assistant surgeon, anesthesiologist, pathologist, and hospital. 6.16.3.1 Instructions for Completing the Abortion Certification Form Field # Ch. 6 Index Action 1 Enter the name of the attending physician or surgeon. 2 Check the option (1, 2 or 3) that is appropriate 3 Enter the name of the client receiving the surgery 4 Enter the client’s address 5 The physician or surgeon performing the abortion will sign and date here. 6 Enter the performing physician’s address. 93 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.16.3.2 NOTE: Abortion Certification Form Click image above to be taken to a printable version of this form. 6.17 Remittance Advice After claims have been processed weekly, Medicaid distributes a Medicaid proprietary Remittance Advice (RA) to providers. The Remittance Advice (RA) plays an important communication role between providers and Medicaid. It explains the outcome of claims submitted for payment. Aside from providing a record of transactions the RA assists providers in resolving potential errors. Providers receiving manual checks will receive their check and RA in the same mailing. The RA is organized in the following manner: The first page or cover page is important and should not be over looked it may include an RA Banner notification from Wyoming Medicaid (1.2.1, RA Banner Notices/Samples). Claims are grouped by disposition category. o Claim Status PAID group contains all the paid claims. o Claim Status DENIED group reports denied claims. o Claim Status PENDED group reports claims pended for review. Do not resubmit these claims. All claims in pended status are reported each payment cycle until paid or denied. Claims can be in a pended status for up to 30-days. o Claim Status ADJUSTED group reports adjusted claims. Ch. 6 Index 94 Revision 4/1/17 Common Billing Information ____________________________________________________ All paid, denied, and pended claims and claim adjustments are itemized within each group in alphabetic order by client last name. A unique Transaction Control Number (TCN) is assigned to each claim. TCNs allow each claim to be tracked throughout the Medicaid claims processing system. The digits and groups of digits in the TCN have specific meanings, as explained below: 0 05180 22 001 0 001 00 Claim Number Type of Document (0=new claim, 1=credit, 2=adjustment) Batch Number Imager Number Year/Julian Date Claim Input Medium Indicator___________ 0=Paper Claim 1=Point of Sale (Pharmacy) 2=Electronic Crossovers sent by Medicare 3=Electronic claims submission 4=Medicaid initiated adjustment 5=Special Processing required The RA Summary Section reports the number of claim transactions, and total payment or check amount. Ch. 6 Index 95 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.17.1 Sample Professional Remittance Advice WYOMING DEPARTMENT OF HEALTH MEDICAID MANAGEMENT INFORMATION SYSTEM R E M I T A N C E RUN DATE 00/00/00 A D V I C E TO: SAMPLE PROVIDER R.A. NO.: 0101010 DATE PAID: 00/00/00 PROVIDER NUMBER: 123456789/1234567890 PAGE: TRANS-CONTROL-NUMBER BILLED MCARE COPAY OTHER DEDUCTCOINS MCAID WRITE TREATING LI SVC-DATE PROC/MODS UNITS AMT. PAID AMT. INS. IBLE AMT. PAID OFF PROVIDER S PLAN * * * CLAIM TYPE: HCFA 1500 * * * CLAIM STATUS: DENIED ORIGINAL CLAIMS: 1 * BRADY TOM RECIP ID: 0000012345 PATIENT ACCT #: 00000 0-03000-22-000-0006-10 80.00 0.00 0.00 0.00 0.00 HEADER EOB(S): 300 147 0.00 0.00 0.00 01 04/28/15 42830 0.00 0.00 0.00 0.00 1234567890 K LTCS * MANNING PEYTON RECIP ID: 0800000001 PATIENT ACCT #: 00001 0-03000-22-000-0006-12 80.00 0.00 0.00 0.00 0.00 HEADER EOB(S): 300 147 0.00 0.00 0.00 01 05/02/15 69436 0.00 0.00 0.00 1234567890 K NH 1 1 80.00 80.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 REMITTANCE ADVICE TO: SAMPLE PROVIDER R.A. NO.: 0101010 DATE PAID: 00/00/00 PROVIDER NUMBER: 1234567890 REMITTANCE T O T A L S PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 0 --------0.00 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------0.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 4 --------320.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 --------0.00 AMOUNT OF CHECK: --------------------------------------------------------------- THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: 147 300 THE TREATING PROVIDER TYPE IS NOT VALID WITH THE PROCEDURE CODE. THE PROVIDER NUMBER CANNOT BE BILLED ON THIS CLAIM TYPE. VERIFY THE PROVIDER IS PAGE: 2 0.00 0.00 0.00 0.00 0.00 0.00 COUNT: 4 4 USING THE CORRECT PROVIDER NUMBER FOR THIS CLAIM TYPE AND RESUBMIT. Ch. 6 Index 96 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.17.2 How to Read the Remittance Advice Each claim processed during the weekly cycle is listed on the Remittance Advice with the following information: FIELD NAME To R.A. Number Date Paid Provider Number Page Last, MI, and First Recip ID Patient Acct # Trans Control Number Billed Amt. Mcare Paid Copay Amt. Other Ins. Deductible Coins Amt. Mcaid Paid Write off Header EOB(s) Li Svc date Proc / Mods Units Billed Amt. Mcare Paid Copay Amt. Other Ins. Deductible Coins Amt. Mcaid Paid Write off Treating Provider S Plan Line EOB(s) Ch. 6 Index HEADER DESCRIPTION Provider Name Remittance Advice Number assigned. Payment date. Medicaid provider number/NPI number Page Number The client’s name as found on the Medicaid ID Card. The client’s Medicaid ID Number. The patient account number reported by the provider on the claim. Transaction Control Number: The unique identifying number assigned to each claim submitted. Total amount billed on the claim Amount paid by Medicare The amount due from the client for their co-payment. Amount paid by other insurance. Medicare deductible amount. Medicare coinsurance amount. The amount paid by Medicaid Difference between Medicaid paid amount and the provider’s billed amount. Explanation of Benefits: A denial code. A description of each code is provided at the end of the RA The line item number of the claim. The date of service. The procedure code and applicable modifier. The number of units submitted. Total amount billed on the line. Amount paid by Medicare The amount due from the client for their co-payment. Amount paid by other insurance. Medicare deductible amount. Medicare coinsurance amount. The amount paid by Medicaid Difference between Medicaid paid amount and the provider’s billed amount. The treating provider’s NPI number. How the system priced each claim. For example, claims priced manually have a distinct code. Claims paid according to the Medicaid fee schedule have another code. Below is a table which describes these pricing source codes: A= Anesthesia M= Manually Priced B= Billed Charge N= Provider Charge C= Percent-of-Charges O= Relative Value Units TC D= Inpatient Per Diem Rate P= Prior Authorization Rate E= EAC Priced Plus Dispensing Fee R= Relative Value Unit Rate F= Fee Schedule S= Relative Value Unit PC G= FMAC Priced Plus Dispensing Fee T= Fee Schedule TC H= Encounter Rate X= Medicare Coinsurance and Deductible I= Institutional Care Rate Y= Fee Schedule PC K= Denied Z = Fee Plus Injection L= Maximum Suspend Ceiling The Medicaid and State Healthcare Benefit Plan the client is eligible for (Section A.3). Explanation of Benefits: A denial code. A description of each code is provided at the end of the RA 97 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.17.3 Remittance Advice Replacement Request Policy If you are unable to obtain a copy from the web portal, a paper copy may be requested as follows: To request a printed replacement copy of a Remittance Advice, complete the following steps: Print the Remittance Advice (RA) replacement request form For replacement of a complete RA contact Provider Relations (2.1, Quick Reference) to obtain the RA number, date and number of pages Replacements of a specific page of an RA (containing a requested specific claim/TCN) will be three (3) pages (the cover page, the page containing the claim, and the summary page for the RA) Review the below chart to determine the cost of the replacement RA (based on total number of pages requested – For multiple RAs requested at the same time, add total pages together) Send the completed form and payment as indicated on the form o Make checks to Division of Healthcare Financing o Mail to Provider Relations (2.1, Quick Reference) The replacement RA will be emailed, faxed or mailed as requested on the form. Email is the preferred method of delivery, and RAs of more than ten (10) pages will not be faxed. RAs less than 24 weeks old can be obtained from the Secured Provider Web Portal, once a provider has registered for access (8.5.2.1, Secured Provider Web Portal Registration Process). Total Number of RA Pages 1-10 11-20 21-30 31-40 41-50 51+ Ch. 6 Index Cost for Replacement RA $2.50 $5.00 $7.50 $10.00 $12.50 Contact Provider Relations for rates 98 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.17.3.1 Remittance Advice (RA) Replacement Request Form NOTE: 6.17.4 Click image above to be taken to a printable version of this form. Obtain an RA from the Web Providers have the ability to view and download their last 24 weeks of RAs from the Medicaid website, refer to Chapter 8, Electronic Data Interchange (EDI). 6.17.5 When a Client Has Other Insurance If the client has other insurance coverage reflected in Medicaid records, payment may be denied unless providers report the coverage on the claim. Medicaid is always the payor of last resort. For exceptions and additional information regarding Third Party Liability, refer to Chapter 7 of this manual. To assist providers in filing with the other carrier, the following information is provided on the RA directly below the denied claim: Ch. 6 Index Insurance carrier name; Name of insured; Policy number; Insurance carrier address; Group number, if applicable; and Group employer name and address, if applicable. 99 Revision 4/1/17 Common Billing Information ____________________________________________________ The information is specific to the individual client. The Third Party Resources Information Sheet (7.7.1, Third Party Resources Information Sheet) should be used for reporting new insurance coverage or changes in insurance coverage on a client’s policy. 6.18 Resubmitting Versus Adjusting Claims Resubmitting and adjusting claims are important steps in correcting any billing problems. Knowing when to resubmit a claim versus adjusting it is important. Action Description Timely Filing Limitation VOID Claim has paid; however, the provider would like to completely cancel the claim as if it was never billed. ADJUST Claim has paid, even if paid $0.00; however, the provider would like to make a correction or change to this paid claim May be completed any time after the claim has been paid. Must be completed within six (6) months after the claim has paid UNLESS the result will be a lower payment being made to the provider, then no time limit. RESUBMIT Claim has denied entirely or a single line has denied, the provider may resubmit on a separate claim. 6.18.1 One (1) year from the date of service. How Long do Providers Have to Resubmit or Adjust a Claim? The deadlines for resubmitting and adjusting claims are different: Providers may resubmit any denied claim or line within 12-months of the date of service. Providers may adjust any paid claim within six (6) months of the date of payment. Adjustment requests for over-payments are accepted indefinitely. However, the Provider Agreement requires providers to notify Medicaid within 30-days of learning of an over-payment. When Medicaid discovers an over-payment during a claims review, the provider maybe notified in writing, in most cases, the over-payment will be deducted from future payments. Refund checks are not encouraged. Refund checks are not reflected on the Remittance Advice. However, deductions from future payments are reflected on the Remittance Advice, providing a hardcopy record of the repayment. Ch. 6 Index 100 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.18.2 Resubmitting a Claim Resubmitting is when a provider submits a claim to Medicaid that was previously submitted for payment but was either returned unprocessed or denied. Electronically submitted claims may reject for X12 submission errors. Claims may be returned to providers before processing because key information such as an authorized signature or required attachment is missing or unreadable. How to Resubmit: Review and verify EOB codes on the RA/835 transaction and make all corrections and resubmit the claim. o Contact Provider Relations for assistance (2.1, Quick Reference). Claims must be submitted with all required attachments with each new submission. If the claim was denied because Medicaid has record of other insurance coverage, enter the missing insurance payment on the claim or submit insurance denial information, when resubmitting the claim to Medicaid. 6.18.2.1 When to Resubmit to Medicaid Claim Denied. Providers may resubmit to Medicaid when the entire claim has been denied, as long as the claim was denied for reasons that can be corrected. When the entire claim is denied, check the explanation of benefits (EOB) code on the RA/835 transaction, make the appropriate corrections, and resubmit the claim. Paid Claim With One (1) or More Line(s) Denied. – Providers may submit individually denied lines. Claim Returned Unprocessed. – When Medicaid is unable to process a claim it will be rejected or returned to the provider for corrections and to resubmit. 6.18.3 Adjustment/Void Request Form Electronically Adjusting Paid Claims via Hardcopy/Paper When a provider identifies an error on a paid claim, the provider must submit an Adjustment/Void Request Form. If the incorrect payment was the result of a keying error (paper claim submission), by the fiscal agent contact Provider Relations to have the claim corrected (2.1, Quick Reference). NOTE: All items on a paid claim can be corrected with an adjustment EXCEPT the pay-to provider number. In this case, the original claim will need to be voided and the corrected claim submitted. Denied claims cannot be adjusted. Ch. 6 Index 101 Revision 4/1/17 Common Billing Information ____________________________________________________ When adjustments are made to previously paid claims, Medicaid reverses the original payment and processes a replacement claim. The result of the adjustment appears on the RA/835 transaction as two (2) transactions. The reversal of the original payment will appear as a credit (negative) transaction. The replacement claim will appear as a debit (positive) transaction and may or may not appear on the same RA/835 transaction as the credit transaction. The replacement claim will have almost the same TCN as the credit transaction, except the 12th digit will be a two (2), indicating an adjustment, whereas the credit will have a one (1) in the 12th digit indicating a debit. 6.18.3.1 Adjustment/Void Request Form NOTE: If a provider wants to void an entire RA, contact Provider Relations (2.1, Quick Reference). Click image above to be taken to a printable version of this form. 6.18.3.2 How to Request an Adjustment/Void To request an adjustment, use the Adjustment/Void Request Form (6.18.3.1, Adjustment/Void Request Form). The requirements for adjusting/voiding a claim are as follows: An adjustment/void can only be processed if the claim has been paid by Medicaid. Ch. 6 Index 102 Revision 4/1/17 Common Billing Information ____________________________________________________ Medicaid must receive individual claim adjustment requests within six (6) months of the claim payment date. A separate Adjustment/Void Request Form must be used for each claim. If the provider is correcting more than one (1) error per claim, use only one (1) Adjustment/Void Request Form, and include all corrections on one form. o If more than one (1) line of the claim needs to be adjusted, indicate which lines and items need to be adjusted in the “Reason for Adjustment or Void” section on the form or simply state, refer to the attached corrected claim. 6.18.3.3 Section Field # How to Complete the Adjustment/Void Request Form Field Name Claim Adjustment 1a, 1b A Void Claim Mark this box if any adjustments need to be made to a claim. Attach a copy of the claim with corrections made in BLUE ink (do not use red ink or highlighter) or the RA. Attach all supporting documentation required to process the claim, i.e. EOB, EOMB, consent forms, invoice, etc. Mark this box if an entire claim needs to be voided. Attach a copy of the claim or the Remittance Advice. 1 17-digit TCN Sections B and C must be completed. Enter the 17-digit transaction control number assigned to each claim from the Remittance Advice. 2 Payment Date Enter the Payment Date 3 B Action 4 5 6 7 C Nine (9) digit Provider or ten (10) digit NPI Number Provider Name Ten (10) digit Client Number Ten (10) digit PA Number Reason for Adjustment or Void Provider Signature and Date Enter provider’s nine (9) digit Medicaid provider number or ten (10) digit NPI number, if applicable. Enter the provider name. Enter the client’s ten (10) digit Medicaid ID number. Enter the ten (10) digit Prior Authorization number, if applicable. Enter the specific reason and any pertinent information that may assist the fiscal agent. Signature of the provider or the provider’s authorized representative and the date. Adjusting a claim electronically via an 837 transaction. Wyoming Medicaid accepts claim adjustments electronically, refer to Chapter 9, Wyoming Specific HIPAA 5010 Electronic Specifications, for complete details. 6.18.3.4 When to Request an Adjustment When a claim was overpaid or underpaid. Ch. 6 Index 103 Revision 4/1/17 Common Billing Information ____________________________________________________ When a claim was paid, but the information on the claim was incorrect (such as client ID, date of service, procedure code, diagnoses, units, etc.) When Medicaid pays a claim and the provider subsequently receives payment from a third party payor, the provider must adjust the paid claim to reflect the TPL amount paid. Attach a corrected claim showing the insurance payment and attach a copy of the insurance EOB if the payment is less than 40% of the total claim charge. For the complete policy regarding Third Party Liability refer to Chapter 7. NOTE: 6.18.3.5 Cannot complete an adjustment when the mistake is the pay-to provider number or NPI. When to Request a Void Request a void when a claim was billed in error (such as incorrect provider number, services not rendered, etc.). 6.19 Credit Balances A credit balance occurs when a provider’s credits (take backs) exceed their debits (pay outs), which results in the provider owing Medicaid money. Credit balances may be resolved in two (2) ways: 1. Working off the credit balance: By taking no action, remaining credit balances will be deducted from future claim payments. The deductions appear as credits on the provider’s RA(s)/835 transaction(s) until the balance owed to Medicaid has been paid. 2. Sending a check payable to the “Division of Healthcare Financing” for the amount owed. This method is typically required for providers who no longer submit claims to Medicaid or if the balance is not paid within 30-days. A notice is typically sent from Medicaid to the provider requesting the credit balance to be paid. The provider is asked to attach the notice, a check and a letter explaining the money is to pay off a credit balance. Include the provider number to ensure the money is applied correctly. NOTE: Ch. 6 Index When a provider number with Wyoming Medicaid changes, but the provider’s tax-id remains the same, the credit balance will be moved automatically from the old Medicaid provider number to the new one, and will be reflected on RAs/835 transactions. 104 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.20 Timely Filing The Division of Healthcare Financing adheres strictly to its timely filing policy. The provider must submit a clean claim to Medicaid within 12-months of the date of service. A clean claim is an error free, correctly completed claim, with all required attachments, that will process and approve to pay within the twelve-month time period. Submit claims immediately after providing services so when a claim is denied, there is time to correct any errors and resubmit. Claims are to be submitted only after the service(s) have been rendered, and not before. For deliverable items (i.e. dentures, DME, glasses, hearing aids, etc.) the date of service must be the date of delivery, not the order date. 6.20.1 Exceptions to the Twelve-Month Limit Exceptions Beyond the Control of the Provider When the Situation is: The Time Limit is: Medicare Crossover A Claim must be submitted within 12-months of the date of service or within six (6) months from the payment date on the Explanation of Medicare Benefits (EOMB), whichever is later. Client is determined to be eligible on appeal, reconsideration, or court decision (retroactive eligibility) Claims must be submitted with in six (6) months of the date of the determination of retroactive eligibility. The client must provide a copy of the dated letter to the provider to document retroactive eligibility. If a claim exceeds timely filing and the provider elects to accept the client as a Medicaid client and bill Wyoming Medicaid, a copy of the notice must me attached to the claim with a cover letter requesting an exception to timely filing. The notice of retroactive eligibility may be a SSI award notice or a notice from WDH. Client is determined to be eligible due to agency corrective actions (retroactive eligibility) Claims must be submitted within six (6) months of the date of the determination of retroactive eligibility. The client must provide a copy of the dated letter to the provider to document retroactive eligibility. If a claim exceeds timely filing and the provider elects to accept the client as a Medicaid client and bill Wyoming Medicaid, a copy of the notice must be attached to the claim with a cover letter requesting an exception to timely filing. Provider finds their records to be inconsistent with filed claims, regarding rendered services. This includes dates of service, procedure/revenue codes, tooth codes, modifiers, admission or discharge dates/times, treating or referring providers or any other item which makes the records/claims non-supportive of each other. Although there is no specific time limit for correcting errors, the corrected claim must be submitted in a timely manner from when the error was discovered. If the claim exceeds timely filing, the claim must be sent with a cover letter requesting an exception to timely filing citing this policy. Ch. 6 Index 105 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.20.2 Appeal of Timely Filing A provider may appeal a denial for timely filing ONLY under the following circumstances: The claim was originally filed within 12-months of the date of service and is on file with Wyoming Medicaid; and The provider made at least one (1) attempt to resubmit the corrected claim within 12-months of the date of service; and The provider must document in their appeal letter all claims information and what corrections they made to the claim (all claims history, including TCNs) as well as all contact with or assistance received from Provider Relations (dates, times, call reference number, who was spoken with, etc.) or A Medicaid computer or policy problem beyond the provider’s control prevented the provider from finalizing the claim within 12-months of the date of service Any appeal that does not meet the above criteria will be denied. Timely filing will not be waived when a claim is denied due to provider billing errors or involving third party liability. 6.20.2.1 How to Appeal The provider must submit the appeal in writing to Provider Relations (2.1, Quick Reference) and should include the following: Documentation of previous claim submission (TCNs, documentation of the corrections made to the subsequent claims); Documentation of contact with Provider Relations An explanation of the problem; and A clean copy of the claim, along with any required attachments and required information on the attachments. A clean claim is an error free, correctly completed claim, with all required attachments, that will process and pay. 6.21 Important Information Regarding Retroactive Eligibility Decisions The client is responsible for notifying the provider of the retroactive eligibility determination and supplying a copy of the notice. A provider is responsible for billing Medicaid only if: They agreed to accept the patient as a Medicaid client pending Medicaid eligibility; or Ch. 6 Index 106 Revision 4/1/17 Common Billing Information ____________________________________________________ After being informed of retroactive eligibility, they elect to bill Medicaid for services previously provided under a private agreement. In this case, any money paid by the client for the services being billed to Medicaid would need to be refunded prior to a claim being submitted to Medicaid. NOTE: The provider determines at the time they are notified of the client’s eligibility if they are choosing to accept the client as a Medicaid client. If the provider does not accept the client, they remain private pay. In the event of retroactive eligibility, claims must be submitted within six (6) months of the date of determination of retroactive eligibility. NOTE: Inpatient Hospital Certification: A hospital may seek admission certification for a client found retroactively eligible for Medicaid benefits after the date of admission for services that require admission certification. The hospital must request admission certification within 30-days after the hospital receives notice of eligibility. To obtain certification, contact WYhealth (2.1, Quick Reference). 6.22 Client Fails to Notify a Provider of Eligibility If a client fails to notify a provider of Medicaid eligibility and is billed as a privatepay patient, the client is responsible for the bill unless the provider agrees to submit a claim to Medicaid. In this case: Any money paid by the client for the service being billed to Wyoming Medicaid must be refunded prior to billing Medicaid; The client can no longer be billed for the service; and Timely filing criterion is in effect. NOTE: The provider determines at the time they are notified of the client’s eligibility if they are choosing to accept the client as a Medicaid client. If the provider does not accept the client, they remain private pay. 6.23 Billing Tips to Avoid Timely Filing Denials File claims soon after services are rendered. Carefully review EOB codes on the Remittance Advice/835 transaction (work RAs/835s weekly). Ch. 6 Index 107 Revision 4/1/17 Common Billing Information ____________________________________________________ Resubmit the entire claim or denied line only after all corrections have been made. Contact Provider Relations (2.1, Quick Reference): o With any questions regarding billing or denials. o When payment has not been received within 30-days of submission, verify the status of the claim. o When there are multiple denials on a claim, request a review of the denials prior to resubmission. NOTE: Once a provider has agreed to accept a patient as a Medicaid client, any loss of Medicaid reimbursement due to provider failure to meet timely filing deadlines is the responsibility of the provider. 6.24 Telehealth Telehealth is the use of an electronic media to link beneficiaries with health professionals in different locations. The examination of the client is performed via a real time interactive audio and video telecommunications system. This means that the client must be able to see and interact with the off-site practitioner at the time services are provided via telehealth technology. It is the intent that telehealth services will provide better access to care by delivering services as they are needed when the client is residing in an area that does not have specialty services available. It is expected that this modality will be used when travel is prohibitive or resources won’t allow the clinician to travel to the client’s location. Each site will be able to bill for their own services as long as they are an enrolled Medicaid provider (this includes out-of-state Medicaid providers). 6.24.1 Covered Services Originating Sites (Spoke Site) The Originating site or Spoke site is the location of an eligible Medicaid client at the time the service is being furnished via telecommunications system occurs. Authorized originating sites are: Hospitals Office of a physician or other practitioner (this includes medical clinics) Office of a psychologist or neuropsychologist Community mental health or substance abuse treatment center (CMHC/SATC) Office of an advanced practice nurse (APN) with specialty of psych/mental health Office of a Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT) Ch. 6 Index 108 Revision 4/1/17 Common Billing Information ____________________________________________________ Federally Qualified Health Center (FQHC) Rural Health Clinic (RHC) Skilled nursing facility (SNF) Indian Health Services Clinic (IHS) Hospital-based or Critical Access Hospital-based renal dialysis centers (including satellites). Independent Renal Dialysis Facilities are not eligible originating sites. Developmental Center Distant Site Providers (Hub Site) The location of the physician or practitioner providing the professional services via a telecommunications system is called the distant site or Hub site. A medical professional is not required to be present with the client at the originating site unless medically indicated. However, in order to be reimbursed, services provided must be appropriate and medically necessary. Physicians/practitioners eligible to bill for professional services are: Physician Advanced Practice Nurse with specialty of Psychiatry/Mental Health Physician’s Assistant Psychologist or Neuropsychologist Licensed Mental Health Professional (LCSW, LPC, LMFT, LAT) Speech Therapist Provisionally licensed mental health professionals cannot bill Medicaid directly. Services must be provided through an appropriate supervising provider. Services provided by non-physician practitioners must be within their scope(s) of practice and according to Medicaid policy. For Medicaid payment to occur, interactive audio and video telecommunications must be permitting real-time communication between the distant site physician or practitioner and the patient with sufficient quality to assure the accuracy of the assessment, diagnosis, and visible evaluation of symptoms and potential medication side effects. All interactive video telecommunication must comply with HIPAA patient privacy regulations at the site where the patient is located, the site where the consultant is located, and in the transmission process. If distortions in the transmission make adequate diagnosis and assessment improbable and a presenter at the site where the patient is located is unavailable to assist, the visit must be halted and rescheduled. It is not appropriate to bill for portions of the evaluation unless the exam was actually performed by the billing provider. The billing provider must comply with all licensing and regulatory laws applicable to the provider’s practice or business in Wyoming and must not currently be excluded from participating in Medicaid by state or federal sanctions. Ch. 6 Index 109 Revision 4/1/17 Common Billing Information ____________________________________________________ 6.24.2 Non-Covered Services Telehealth does not include a telephone conversation, electronic mail message (email), or facsimile transmission (fax) between a healthcare practitioner and a patient. 6.24.3 Billing Requirements In order to obtain Medicaid reimbursement for services delivered through telehealth technology, the following standards must be observed: The services must be medically necessary and follow generally accepted Ch. 6 Index standards of care. The service must be a service covered by Medicaid. Claims must be made according to Medicaid billing instructions. The same procedure codes and rates apply as for services delivered in person. Quality assurance/improvement activities relative to telehealth delivered services need to be identified, documented and monitored. Providers need to develop and document evaluation processes and patient outcomes related to the telehealth program, visits, provider access, and patient satisfaction. All service providers are required to develop and maintain written documentation in the form of progress notes the same as is originated during an in-person visit or consultation with the exception that the mode of communication (i.e. teleconference) should be noted. Medicaid will not reimburse for the use or upgrade of technology, for transmission charges, for charges of an attendant who instructs a patient on the use of the equipment or supervises/monitors a patient during the telehealth encounter, or for consultations between professionals. o The modifier to indicate a telehealth service is “GT” which must be used in conjunction with the appropriate procedure code to identify the professional telehealth services provided by the distant site provider (e.g., procedure code 90832 billed with modifier GT). Using the GT modifier does not change the reimbursement fee. o When billing for the originating site facility fee, use procedure code Q3014. A separate or distinct progress note isn’t required to bill Q3014. Validation of service delivery would be confirmed by the accompanying practitioner’s claim with the GT modifier indicating the practitioner’s service was delivered via telehealth. Medicaid will reimburse the originating site provider the lesser of charge or the current Medicaid fee. o Additional services provided at the originating site on the same date as the telehealth service may be billed and reimbursed separately according to published policies and the national correct coding initiative guidelines. 110 Revision 4/1/17 Common Billing Information ____________________________________________________ o For ESRD-related services, at least one (1) face-to-face, “hands on” visit (not telehealth) must be furnished each month to examine the vascular access site by a qualified provider. NOTE: If the patient and/or legal guardian indicate at any point that he/she wants to stop using the technology, the service should cease immediately and an alternative appointment set up. Hub Sites Billing Code(s) (site with provider) CPT-4 and HCPCS Level II Codes 99241-99255 99201-99215 90832-90838 Modifier GT GT GT 90791-90792 GT 96116 90951,90952,90954,90955,90957,90958,90960 and 90961 GT G0270 GT H0031, H2019, T1007, T1017, H0006, G9012 GT 92586, 92602, 92604, 92626 GT GT Modifier Description GT Telehealth Service Description Consultations Office or other outpatient visits Psychotherapy Psychiatric diagnostic interview examination Neurobehavioral status exam End stage renal disease related services Individual medical nutrition therapy Mental Health and Substance Abuse Treatment Services Remote Cochlear Implant Spoke Site Billing Code (site with patient) HCPCS Level II Code Description Q3014 Telehealth originating site facility fee For accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). Ch. 6 Index 111 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ Chapter Seven – Third Party Liability 7.1 Definition of a Third Party Liability ................................................................. 113 7.1.1 Third Party Liability (TPL) ............................................................................... 113 7.1.2 Third Party Payer............................................................................................... 113 7.1.3 Medicare ............................................................................................................ 114 7.1.4 Medicare Replacement Plans ............................................................................ 114 7.1.5 Disability Insurance Payments .......................................................................... 114 7.1.6 Long-Term Care Insurance ............................................................................... 114 7.1.7 Exceptions ......................................................................................................... 114 Provider’s Responsibilities ................................................................................ 115 7.2 7.2.1 Third Party Resources Information Sheet ......................................................... 116 7.2.2 Provider is not enrolled with TPL Carrier ......................................................... 116 7.2.3 Medicare Opt-Out.............................................................................................. 117 7.3 Billing Requirements ......................................................................................... 117 7.3.1 7.3.1.1 How TPL is applied ........................................................................................... 119 Previous Attempts to Bill Services Letter ..................................................... 120 7.3.2 Acceptable proof of Payment or Denial ............................................................ 120 7.3.3 Coordination of Benefits ................................................................................... 121 7.3.4 Blanket Denials and Non-Covered Services ..................................................... 121 7.3.5 TPL and Copays ................................................................................................ 121 7.4 Medicare Pricing ............................................................................................... 122 7.4.1 Medicaid Covered Services ............................................................................... 122 7.4.2 Medicaid Non-Covered Services....................................................................... 122 7.4.3 Coinsurance and Deductible .............................................................................. 123 Ch. 7 Index 112 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.1 Definition of a Third Party Liability 7.1.1 Third Party Liability (TPL) TPL is defined as the right of the department to recover, on behalf of a client, from a third party payer the costs of Medicaid services furnished to the client (Wyoming Department of Health, Medicaid Rules, Chapter 1, Section 3 Part (b) subpart (ccxlviii)). In simple terms, third party liability (TPL) is often referred to as other insurance, other health insurance, medical coverage, or other insurance coverage. Other insurance is considered a third-party resource for the client. Third-party resources may include but are not limited to: 7.1.2 Health insurance (including Medicare) Vision coverage Dental coverage Casualty coverage resulting from an accidental injury or personal injury Payments received directly from an individual who has either voluntarily accepted or been assigned legal responsibility for the health care of one or more clients. Third Party Payer Third Party Payer is defined as a person, entity, agency, insurer, or government program that may be liable to pay, or that pays pursuant to a client’s right of recovery arising from an illness, injury, or disability for which Medicaid funds were paid or are obligated to be paid on behalf of the client. Third party payers include, but are not limited to: Medicare Medicare Replacement (Advantage or Risk Plans) Medicare Supplemental Insurance Insurance Companies Other o Disability Insurance o Workers’ Compensation o Spouse or parent who is obligated by law or by court order to pay all or part of such costs (absent parent) o Client’s estate o Title 25 Medicaid is the payor of last resort. It is a secondary payer to all other payment sources and programs and should be billed only after payment or denial has been received from such carriers. Ch. 7 Index 113 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.1.3 Medicare Medicare is administered by the Centers for Medicare and Medicaid Services (CMS) and is the federal health insurance program for individuals age 65 and older, certain disabled individuals, individuals with End Stage Renal Disease (ESRD) and amyotrophic lateral sclerosis (ALS). Medicare entitlement is determined by the Social Security Administration. Medicare is primary to Medicaid. Services covered by Medicare must be provided by a Medicare-enrolled provider and billed to Medicare first. 7.1.4 Medicare Replacement Plans Medicare Replacement Plans are also known as Medicare Advantage Plans or Medicare Part C and are treated the same as any other Medicare claim. Many companies have Medicare replacement policies. Providers must verify whether or not a policy is a Medicare replacement policy. If the policy is a Medicare replacement policy, the claim should be entered as any other Medicare claim. 7.1.5 Disability Insurance Payments If the disability insurance carrier pays for health care items and services, the payments must be assigned to Wyoming Medicaid. The client may choose to receive a cash benefit. If the payments from the disability insurance carrier are related to a medical event that required submission of claims for payment, the reimbursement from the disability carrier is considered a third party payment. If the disability policy does not meet any of these, payments made to the Wyoming Medicaid client may be treated as income for Medicaid eligibility purposes. 7.1.6 Long-Term Care Insurance When a long-term care (LTC) insurance policy exists, it must be treated as TPL and be cost-avoided. The provider must either collect the LTC policy money from the client or have the policy assigned to the provider. However, if the provider is a nursing facility and the LTC payment is sent to the client, the monies are considered income. The funds will be included in the calculation of the client’s patient contribution to the nursing facility. 7.1.7 Exceptions The only exceptions to this policy are referenced below: Children’s Special Health (CSH) – Medical claims are sent to Wyoming Medicaid’s MMIS fiscal agent Indian Health Services (IHS) – 100% federally funded program Ryan White Foundation – 100% federally funded program Wyoming Division of Victim Services/Wyoming Crime Victim Compensation Program Ch. 7 Index 114 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ Policyholder is an absent parent Upon billing Medicaid, providers are required to certify if a third party has been billed prior to submission. The provider must also certify that they have waited 30 days from the date of service before billing Medicaid and has not received payment from the third party Services are for preventative pediatric care (Early and Periodic Screening, Diagnosis, and Treatment/EPSDT), prenatal care. NOTE: Inpatient labor and delivery services and post-partum care must be cost avoided or billed to the primary health insurance. See State Medicaid Manual Section 3904.3B – Prenatal and Preventative Pediatric Care. An internet search may be performed to locate this citation by performing an internet query of the State Medicaid Manual, select Chapter 3 and go to Section sm_3_3900_to_3910.15. The probable existence of third-party liability cannot be established at the time the claim is filed. Home and community based (HCBS) waiver services as most insurance companies do not cover these types of services. NOTE: It may be in the provider’s best interest to bill the primary insurance themselves, as they may receive higher reimbursement from the primary carrier. 7.2 Provider’s Responsibilities Providers have an obligation to investigate and report the existence of other thirdparty liability information. Providers play an integral and vital role as they have direct contact with the client. The contribution providers make to Medicaid in the TPL arena is significant. Their cooperation is essential to the functioning of the Medicaid Program and to ensuring prompt payment. At the time of client intake, the provider must obtain Medicaid billing information from the client. At the same time, the provider should also ascertain if additional insurance resources exist. When a TPL/Medicare has been reported to the provider, these resources must be identified on the claim in order for claims to be processed properly. Other insurance information may be reported to Medicaid using the Third Party Resources Information Sheet. Claims should not be submitted prior to billing TPL/Medicare. Ch. 7 Index 115 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.2.1 Third Party Resources Information Sheet NOTE: Click image above to be taken to a printable version of this form. Medicaid maintains a reference file of known commercial health insurance as well as a file for Medicare Part A and Part B entitlement information. Both files are used to deny claims that do not show proof of payment or denial by the commercial health insurer or by Medicare. Providers must use the same procedures for locating third party payers for Medicaid clients as for their non-Medicaid clients. Providers may not refuse to furnish services to a Medicaid client because of a third party’s potential liability for payment for the service (S.S.A. §1902(a)(25)(D)) (3.2 Accepting Medicaid Clients) 7.2.2 Provider is not enrolled with TPL Carrier Medicaid will no longer accept a letter with a claim indicating that a provider does not participate with a specific health insurance company. The provider must work with the insurance company and/or client to have the claim submitted to the carrier. Providers cannot refuse to accept Medicaid clients who have other insurance if their office does not bill other insurance. However, a provider may limit the number of Medicaid clients s/he is willing to admit into his/her practice. The provider may not discriminate in establishing a limit. If a provider chooses to opt-out of participation with a health insurance or governmental insurance, Medicaid will not pay for services covered by, but not billed to, the health insurance or governmental insurance. Ch. 7 Index 116 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.2.3 Medicare Opt-Out Providers may choose to opt-out of Medicare. However, Medicaid will not pay for services covered by, but not billed to, Medicare because the provider has chosen not to enroll in Medicare. The provider must enroll with Medicare if Medicare will cover the services in order to receive payment from Medicaid. NOTE: In situations where the provider is reimbursed for services and Medicaid later discovers a source of TPL, Medicaid will seek reimbursement from the TPL source. If a provider discovers a TPL source after receiving Medicaid payment, they must complete an adjustment to their claim within 30 days of receipt of payment from the TPL source. 7.3 Billing Requirements Providers should bill TPL/Medicare and receive payment to the fullest extent possible before billing Medicaid. The provider must follow the rules of the primary insurance plan (such as obtaining prior authorization, obtaining medical necessity, obtaining a referral or staying in-network) or the related Medicaid claim will be denied. Follow specific plan coverage rules and policies. CMS does not allow federal dollars to be spent if a client with access to other insurance does not cooperate or follow the applicable rules of his or her other insurance plan. Medicaid will not pay for and will recover for payments made for services that could have been covered by the TPL/Medicare if the applicable rules of that plan had been followed. It is important that providers maintain adequate records of the third-party recovery efforts for a period of time not less than six (6) years after the end of the state fiscal year. These records, like all other Medicaid records, are subject to audit/postpayment review by Health and Human Services, the Centers for Medicare and Medicare Services (CMS), the state Medicaid agency, or any designee. NOTE: If a procedure code requires a prior authorization (PA) for Medicaid payment, but not required by TPL/Medicare, it is still highly recommended to obtain a PA through Medicaid in case TPL/Medicare denies services. Once payment/denial is received by TPL/Medicare, the claim may then be billed to Medicaid as a secondary claim. If payment is received from the other payer, the provider should compare the amount received with Medicaid’s maximum allowable fee for the same claim. If payment is less than Medicaid’s allowed amount for the same claim, indicate the payment in the appropriate field on the claim form. o CMS 1500 – TPL paid amount will be indicated in box 29 Amount Paid Ch. 7 Index 117 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ o CMS 1500 – Medicare paid amount will not be indicated on the claim, a COB must be attached for claim processing o UB-04 –TPL/Medicare amount will be indicated in box 54 Prior Payments o Dental – TPL/Medicare amount will be indicated in box 33A Other Fees If the TPL payer paid less than 40% of the total billed charges, include the appropriate claim reason and remark codes or attach an explanation of benefits (EOB) with the electronic claim (Electronic Attachments). If payment is received from the other payer after Medicaid already paid the claim, Medicaid’s payment must be refunded for either the amount of the Medicaid payment or the amount of the insurance payment, whichever is less. A copy of the EOB from the other payer must be included with the refund showing the reimbursement amount. NOTE: Medicaid will accept refunds from a provider at any time. Timely filing will not apply to adjustments where money is owed to Medicaid (6.20 Timely Filing). If denial is obtained from the third party payer/Medicare that a service is not covered, attach the denial to the claim (6.15 Submitting Attachments for Electronic Claims). The denial will be accepted for one (1) calendar year, but will still need to be attached with each claim. If verbal denial is obtained from a third party payer, type a letter of explanation on official office letterhead. The letter must include: o Date of verbal denial o Payer’s name and contact person’s name and phone number o Date of Service o Client’s name and Medicaid ID number o Reason for denial If the third party payer/Medicare sends a request to the provider for additional information, the provider must respond. If the provider complies with the request for additional information and after ninety (90) days from the date of the original Ch. 7 Index 118 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ claim and the provider has not received payment or denial, the provider may submit the claim to Medicaid with the Previous Attempts to Bill Services Letter. NOTE: Waivers of timely filing will not be granted due to unresponsive third party payers. In situations involving litigation or other extended delays in obtaining benefits from other sources, Medicaid should be billed as soon as possible to avoid timely filing. If the provider believes there may be casualty insurance, contact TPL Unit (2.1 Quick Address and Telephone Reference) TPL will investigate the responsibility of the other party. Medicaid does not require providers to bill a third party when liability has not been established. However, the provider cannot bill the casualty carrier and Medicaid at the same time. The provider must choose to bill Medicaid or the casualty carrier (estate). Medicaid will seek recovery of payments from liable third parties. If providers bill the casualty carrier (estate) and Medicaid, this may result in duplicate payments. If the client receives reimbursement from the primary insurance, the provider must pursue payment form the patient. If there are any further Medicaid benefits allowed after the other insurance payment, the provider may still submit a claim for those benefits. The provider, on submission, must supply all necessary documentation of the other insurance payment. Medicaid will not pay the provider the amount paid by the other insurance. Providers may not charge Medicaid clients, or any other financially responsible relative or representative of that individual any amount in excess of the Medicaid paid amount. Medicaid payment is payment in full. There is no balance billing. 7.3.1 How TPL is applied The amount paid to providers by primary insurance payers is often less than the original amount billed, for the following reasons: Reductions resulting from a contractual agreement between the payer and the provider (contractual write-off); and, Reductions reflecting patient responsibility (copayment, coinsurance, deductible, etc.). Wyoming Medicaid will pay no more than the remaining patient responsibility (PR) after payment by the primary insurance. Wyoming Medicaid will reimburse the provider for the patient liability up to the Medicaid Allowable Amount. A provider must include the contract write-off amount and the amount paid by the other insurance as the third party liability payment. (See the State Medicaid Manual Chapter 3, Section 3904.7 for more information.) TPL is applied to claims at the header level. Medicaid does not apply TPL amounts line by line. Example: Ch. 7 Index Total claim billed to Medicaid is for $100.00, with a Medicaid allowable for the total claim of $50.00. TPL has paid $25.00 for only the second line of the 119 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ claim. Claim will be processed as follows: Medicaid allowable ($50.00) minus the TPL paid amount ($25) = $25.00 Medicaid Payment. If the payer does not respond to the first attempt to bill with a written or electronic response to the claim within sixty (60) days, resubmit the claims to the TPL. Wait an additional thirty (30) days for the third party payer to respond to the second billing. If after ninety (90) days from the initial claim submission the insurance still has not responded, bill Medicaid with the Previous Attempts to Bill Services Letter. NOTE: Waivers of timely filing will not be granted due to unresponsive third party payers. 7.3.1.1 Previous Attempts to Bill Services Letter NOTE: Do not submit this form for Medicare or automobile/casualty insurance. Click image above to be taken to a printable version of this form. 7.3.2 Acceptable proof of Payment or Denial Documentation of proper payment or denial of TPL/Medicare must correspond with the client’s/beneficiary’s name, date of service, charges, and TPL/Medicare payment referenced on the Medicaid claim. If there is a reason why the charges do not match (i.e. other insurance requires another code to be billed, institutional and professional charges are on the same EOB, third party payer is Medicare Advantage plan, replacement plan or supplement plan) this information must be written on the attachment. Ch. 7 Index 120 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.3.3 Coordination of Benefits Coordination of Benefits (COB) is the process of determining which source of coverage is the primary payer in a particular situation. COB information must be complete, indicate the payer, payment date and the payment amount. If a client has other applicable insurance, providers who bill electronic and web claims will need to submit the claim COB information provided by the other insurance company for all affected services. For claims submitted through the Medicaid website, see the Web Portal Tutorials on billing secondary claims. For clients with three insurances, tertiary claims cannot be submitted through the Medicaid Web Portal and will need to be sent in on paper, with both EOBs and a cover sheet indicating that the claim is a tertiary claim. 7.3.4 Blanket Denials and Non-Covered Services When a service is not covered by a client’s primary insurance plan, a blanket denial letter should be requested from the TPL/Medicare. The insurance carrier should then issue, on company letterhead, a document stating the service is not covered by the insurance plan. The provider can also provide proof from a benefits booklet from the other insurance, as it shows that the service is not covered or the provider may use benefits information from the carrier’s website. Providers should retain this statement in the client’s file to be used as proof of denial for one calendar year. The noncovered status must be reviewed and a new letter obtained as the end of one calendar year. If a client specific denial letter or EOB is received, the provider may use that denial or EOB as valid documentation for the denied services for that member for one calendar year. The EOB must clearly state the services are not covered. The provider must still follow the rules of the primary insurance prior to filing the claim to Medicaid. 7.3.5 TPL and Copays A client with private health insurance primary to Wyoming Medicaid is required to pay the Wyoming Medicaid copay. Submit the claim to Wyoming Medicaid in the usual manner, reporting the insurance payment on the claim with the balance due. If the Wyoming Medicaid allowable covers all or part of the balance billed, Wyoming Medicaid will pay up to the maximum Wyoming Medicaid allowable amount, minus any applicable Wyoming Medicaid copay. Wyoming Medicaid will deduct the copay from its payment amount to the provider and report it as the copay amount on the provider’s RA. Remember, Wyoming Medicaid is only responsible for the client’s liability amount or patient responsibility amount up to its maximum allowable amount. Submit claims to Wyoming Medicaid only if the TPL payer indicates a patient responsibility. If the TPL does not attribute charges to patient responsibility or noncovered services, Wyoming Medicaid will not pay. Ch. 7 Index 121 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ 7.4 Medicare Pricing Effective dates of service beginning January 1, 2017, Wyoming Medicaid changed how reimbursement is calculated for Medicare crossover claims. This change applies to all service providers. 7.4.1 Part B crossovers are processed and paid at the line level (line by line) Part A inpatient crossovers, claims are processed at the header level Part A outpatient crossovers, claims are priced at the line level (line by line) totaled, and then priced at the header level Medicaid Covered Services For services covered under the Wyoming Medicaid State Plan, the methodology will consider what Medicaid would have paid, had it payer. Medicaid’s payment responsibility for a claim will be the Medicare coinsurance and deductible, or the difference between payment and Medicaid allowed charge(s). new payment been the sole lesser of the the Medicare Example: Procedure Code 99239 o Medicaid Allowable - $97.67 o Medicare Paid - $83.13 o Medicare assigned Coinsurance and Deductible - $21.21 First payment method option: (Medicaid Allowable) $97.67 – (Medicare Payment) $83.13 = $14.54 Second payment method option: Coinsurance and deductible = $21.21 o Medicaid will pay the lesser of the Medicaid payment methodology or the coinsurance and deductible This procedure code would pay $14.54 since it is less than $21.21 NOTE: If the method for Medicaid covered services results in a Medicaid payment of $0 and the claim contains lines billed for physician-administered pharmaceuticals, the line will pay out at $0.01. 7.4.2 Medicaid Non-Covered Services For specific Medicare services which are not otherwise covered by Wyoming Medicaid State plan, Medicaid will use a special rate or method to calculate the amount Medicaid would have paid for the service. This method is Medicare allowed amount, divided by 2, minus the Medicare paid amount. Ch. 7 Index 122 Revision 4/1/17 Third Party Liability_______ ____________________________________________________ Example: Procedure Code: E0784 – (Not covered as a rental – no allowed amount has been established for Medicaid) o Medicaid Allowable – Not assigned o Medicare Allowable - $311.58 o Medicare Paid – $102.45 o Assigned Coinsurance and Deductible - $209.13 First payment method option: [(Medicare Allowable 311.58 ÷ 2)] – 102.45 Medicare paid amount = $155.79 (Calculated Medicaid allowable) – (Medicare Paid Amount) 102.45 = $53.34 Second payment method option: Coinsurance and deductible = 209.13 o Medicaid will pay the lesser of the Medicaid payment methodology or the coinsurance and deductible This procedure code would pay $53.34 since it is less than $209.13 NOTE: If the method for Medicaid non-covered services results in a Medicaid payment of $0 and the claim contains lines billed for physicianadministered pharmaceuticals, the line will pay out at $0.01. 7.4.3 Coinsurance and Deductible For clients on the QMB plan, CMS guidelines indicate that coinsurance and deductible amounts remaining after Medicare pays cannot be billed to the client under any circumstances, regardless of whether you bill Medicaid or not. For clients on other plans who are dual eligible, coinsurance and deductible amounts remaining after Medicare payment cannot be billed to the client if the claim was billed to Wyoming Medicaid, regardless of payment amount (including claims that Medicaid pays at $0). If the claim is not billed to Wyoming Medicaid, and the provider agrees in writing prior to providing the service not to accept the client as a Medicaid client and advises the client of his or her financial responsibility, and the client is not on a QMB plan, then the client can be billed for the coinsurance and deductible under Medicare guidelines. Ch. 7 Index 123 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ Chapter Eight – Electronic Data Interchange (EDI) 8.1 What is Electronic Data Interchange (EDI)? ..................................................... 125 8.2 Benefits .............................................................................................................. 125 8.3 Standard Transaction Formats ........................................................................... 125 8.4 Sending and Receiving Transactions ................................................................ 126 8.5 EDI Services ...................................................................................................... 127 8.5.1 Getting Started ................................................................................................... 127 8.5.2 Web Portal ......................................................................................................... 128 8.5.2.1 Secured Provider Web Portal Registration Process ....................................... 128 8.5.2.2 Creating an Office Administrator .................................................................. 128 8.5.2.3 Creating Additional Users ............................................................................. 129 8.5.3 8.5.3.1 WINASAP ......................................................................................................... 129 WINASAP Start-up ....................................................................................... 129 8.6 Additional Information Sources ........................................................................ 131 8.7 Scheduled Web Portal Downtime ..................................................................... 131 Ch. 8 Index 124 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ 8.1 What is Electronic Data Interchange (EDI)? In its simplest form, EDI is the electronic exchange of information between two (2) business concerns (trading partners), in a specific, predetermined format. The exchange occurs in basic units called transactions, which typically relate to standard business documents, such as healthcare claims or remittance advices. 8.2 Benefits Several immediate advantages can be realized by exchanging documents electronically: Speed – Information moving between computers moves more rapidly, and with little or no human intervention. Sending an electronic message across the country takes minutes or less. Mailing the same document will usually take a minimum of one (1) day. Accuracy – Information that passes directly between computers without having to be re-entered eliminates the chance of data entry errors. Reduction in Labor Costs – In a paper-based system, labor costs are higher due to data entry, document storage and retrieval, document matching, etc. As stated above, EDI only requires the data to be keyed once, thus lowering labor costs. 8.3 Standard Transaction Formats In October 2000, under the authority of the Health Insurance Portability and Accountability Act (HIPAA), the Department of Health and Human Services (DHHS) adopted a series of standard EDI transaction formats developed by the Accredited Standards Committee (ASC) X12N. These HIPAA-compliant formats cover a wide range of business needs in the healthcare industry from eligibility verification to claims submission. The specific transaction formats adopted by DHHS are listed below. Ch. 8 Index X12N 270/271 Eligibility Benefit Inquiry and Response X12N 276/277 Claims Status Request and Response X12N 278 Request for Prior Authorization and Response X12N 277CA Implementation Guide Error Reporting X12N 835 Claim Payment/Remittance Advice X12N 837 Dental, Professional and Institutional Claims X12N 999 Functional Acknowledgement 125 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ NOTE: 8.4 As there is no business need, Medicaid does not currently accept nor generate X12N 820 and X12N 834 transactions. Sending and Receiving Transactions Medicaid has established a variety of methods for providers to send and receive EDI transactions. The following table is a guide to understanding and selecting the best method. Method Requirements EDI Options Access Transactions Cost Supported Contact Information X12N 270/271 Eligibility Benefit Inquiry and Response Computer Bulletin Board System (BBS) The BBS is an interactive, menudriven bulletin board system for uploading and downloading transactions. X12N 276/277 Claims Status Request and Response Hayes-compatible 9600-baud or greater asynchronous modem Dial-up connection utility (e.g., ProComm, Hyperterminal, etc.) X12N 278 Request for Prior Authorization and Response Free File decompression utility X12N 277CA Implementation Guide Error Reporting X12N 835 Claim Payment/Remittance Advice Software capable of formatting and reading EDI transactions Telephone connectivity X12N 837 Dental, Professional and Institutional Claims Web Portal Computer The Medicaid Secure Web Portal provides an interactive, webbased interface for entering individual transactions and a separate data exchange facility for uploading and downloading batch transactions. Internet Explorer 5.5 (or higher) or Netscape Navigator 7.0 (or higher). Whichever browser version is used, it must support 128-bit encryption X12N 999 Functional Acknowledgement X12N 270/271 Eligibility Benefit Inquiry and Response Ch. 8 Index Free X12N 276/277 Claims Status Request and Response Internet access X12N 278 Request for Prior Authorization and Response Additional requirements for X12N 277CA Implementation Guide 126 EDI Services Telephone: (800)672-4959 9-5pm MST M-F OPTION 3 Website: http://www.acsgcro.com/gcro/ EDI Services Telephone: (800)672-4959 9-5pm MST M-F OPTION 3 Website: http://wyequalitycare.acsinc.com/ Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ EDI Options Method Requirements Access Cost uploading and downloading batch transactions: File decompression utility. Software capable of formatting and reading EDI transactions Transactions Supported Contact Information Error Reporting X12N 835 Claim Payment/Remittance Advice X12N 837 Dental, Professional and Institutional Claims* X12N 999 – Functional Acknowledgement NOTE: Only the 278 and 837 transactions can be entered interactively. Computer WINASAP 2003 Windows Accelerated Submission and Processing (WINASAP) is a Windows-based software application that allows users to enter and submit dental, professional and institutional claims electronically using a personal computer. Hayes-compatible 9600-baud asynchronous modem Windows 98 (or higher) operating system X12N 837 Dental, Professional and Institutional Claims Pentium processor Free 25 megabytes of free disk space 128 megabytes of RAM X12N 277CAImplementation Guide Error Reporting X12N 999 – Functional Acknowledgement EDI Services Telephone: (800)672-4959 9-5pm MST M-F OPTION 3 Website: http://www.acsgcro.com/ Monitor resolution of 800 x 600 pixels Telephone connectivity 8.5 EDI Services 8.5.1 Getting Started The first step the provider needs to complete before the provider is able to start sending electronic information is to complete the EDI Enrollment Application. The application is located on the Medicaid website (2.1, Quick Reference) under “Forms” and “Enrollment/Agreement Forms”. Ch. 8 Index 127 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ Once the form is completed and sent to Medicaid the provider will be sent an EDI Welcome Letter which will include a User Name and Password. Below are the benefits of using Web Portal and WINASAP and instructions for registering. NOTE: 8.5.2 Web Portal Tutorials and WINASAP Tutorials are published to the Medicaid website (2.1, Quick Reference). Web Portal The Web Portal allows all trading partners to retrieve and submit data via the internet 24-hours a day, seven (7) days a week from anywhere. 8.5.2.1 Secured Provider Web Portal Registration Process Go to the Medicaid website: http://wymedicaid.acs-inc.com. Select Provider. Select Provider Portal from the left hand menu. Under “New Providers” select Web Portal to register. Enter the following information from the EDI Welcome Letter: o Provider ID: Trading Partner/Submitter ID. o Trading Partner ID: Trading Partner/Submitter ID. o EIN/SSN: The Providers tax-id as entered on the EDI application. o Trading Partner Password: Password/User ID – Must be entered exactly as shown on the welcome letter. Select Continue o Confirm that the information that the provider has entered is correct. If it is, choose Continue, if not re-enter information. Additional Trading Partner IDs: o If the provider needs to enter additional Trading Partner IDs enter the ID and the Trading Partner password on this page. o If the provider does not have any additional Trading Partner IDs select continue. 8.5.2.2 Creating an Office Administrator The providers Office Administrator will be the person responsible for adding and deleting new users as necessary for the provider’s organization along with any other privileges selected. 1. Select Create a new user. a. Enter a unique user ID, last name, first name, email address and phone number for the person that the provider wants to be the office administrator. b. Confirm the information entered is correct. Ch. 8 Index 128 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ c. This completes the web registration for the office administrator, an email will be sent to the email address entered with a one (1) time use password. d. Once the provider receives the single use password, (it is easiest to copy and paste this directly from the email to avoid typographical errors) and must be changed upon logging in for the first (1st) time. Return to the home page and log in. 2. All permissions will be set once the provider has logged in. To do this, select update or remove users. Enter the provider user ID and select search. When the user information is brought up, click on the user ID link. a. Select which privileges the provider wishes to have. Once the provider has chosen these privileges click Submit. 8.5.2.3 Creating Additional Users 1. Return to the home page and choose Manage Users. a. Follow the steps as listed above. 8.5.3 WINASAP WINASAP allows all Trading Partners to submit claims 24-hours a day, seven (7) days a week from any computer with a dial up modem over an analog phone line that the provider has installed the software on. WINASAP can be downloaded from the ACS EDI Gateway, Inc. website (2.1, Quick Reference) or the provider can call EDI Services (2.1, Quick Reference) and request a CD to be mailed to the provider. Requirements: Windows 98 Second Edition, Windows NT, Windows 2000 (Service Pack 3), 8.5.3.1 Windows XP or Windows 7 operating system Pentium processor CD-ROM drive 25 Megabytes of free disk space 128 Megabytes of RAM Monitor resolution of 800 x 600 pixels Hayes compatible 9600 baud asynchronous modem Telephone connectivity WINASAP Start-up 1. Download program from the ACS EDI Gateway, Inc. website or install the program from the CD the provider requested. a. When the welcome screen appears click next b. Read and accept the terms of the Software License Agreement Ch. 8 Index 129 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ c. Enter User Information d. Choose Destination Location e. Confirm provider current settings and choose Next f. Check Yes, launch the program file and Finish. 2. Creating a WINASAP login a. The user ID auto fills as ADMIN b. Tab to password and type ASAP i. The user ID and password are the same for everyone using WINASAP, we suggest that the provider does not change them c. After successfully logging in choose ok 3. Steps that must be completed a. The screen will automatically open the first (1st) time the provider runs the program that says Open Payer i. Select Wyoming Medicaid and choose OK ii. Choose File and Trading Partner – Enter the following iii. Primary Identification: Enter the provider Trading Partner ID from the EDI Welcome Letter iv. Secondary Identification – Re-enter the provider Trading Partner ID (primary and secondary identification will be the same) b. Trading Partner Name: i. Entity Type: select person or non-person. 1. Choose person if the provider is an individual such as; a waiver provider, physician, therapist, or nurse practitioner 2. Choose non-person if the provider is a facility such as; a hospital, pharmacy or nursing home. c. Enter the providers last name, first name and middle initial (optional) OR the organization name i. Contact Information: 1. Contact Name: provider Name 2. Telephone Number: Enter provider phone number 3. Fax Number: Enter provider fax number (optional) 4. Email: Enter provider email address 4. The following criteria must be completed: a. WINASAP2003 Communications: i. Host Telephone Number: This phone number is listed as the Submission Telephone Number on the EDI Welcome Letter. Enter it with no spaces, dashes, commas, or other punctuation marks. ii. User ID Number: Enter providers Password/User ID exactly as it appears. iii. User Name: Enter providers User Name exactly as it appears. iv. Choose Save Ch. 8 Index 130 Revision 4/1/17 Electronic Data Interchange (EDI)________________________________________________ 8.6 Additional Information Sources For more information regarding EDI, please refer to the following websites: Centers for Medicare and Medicaid Services: www.cms.gov/hipaa2/default.asp. This is the official HIPAA website of the Centers for Medicare & Medicaid service. Washington Publishing Co.: http://www.wpc-edi.com/hipaa/HIPAA_40.asp. This website is the official source of the implementation guides for each of the ASC X12 N transactions. Workgroup for Electronic Data Interchange: http://www.wedi.org/. This industry group promotes electronic transactions in the healthcare industry. Designated standard maintenance organizations: http://www.hipaa-dsmo.org/. This website explains how changes are made to the transaction standards. 8.7 Scheduled Web Portal Downtime Scheduled Web Portal Downtime What is Impacted Entire website (Provider/Client) Static web pages http://wymedicaid.acsinc.com/ Secured Provider Web Portal http://wyequalitycare.acsinc.com/wy/general/home. do Ch. 8 Index Functionality Impact Why Regular Website not available scheduled maintenance Verification of claims submission will not be available 131 Regular scheduled maintenance Downtimes 4 a.m. – 4:30 a.m. MST Saturdays 3 p.m. – 6 p.m. MST Sundays 10 p.m. – 12 a.m. (midnight) Sundays Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ Chapter Nine – Wyoming HIPAA 5010 Electronic Specifications 9.1 Wyoming Specific HIPAA 5010 Electronic Specifications.............................. 134 9.2 Transaction Definitions ..................................................................................... 134 9.3 Transmission Methods and Procedures ............................................................. 134 9.3.1 Asynchronous Dial-up ....................................................................................... 134 9.3.1.1 Communication Protocols ............................................................................. 135 9.3.1.2 Teleprocessing Requirements ........................................................................ 135 9.3.1.3 Teleprocessing Settings ................................................................................. 135 9.3.1.4 Transmission Procedures ............................................................................... 136 9.3.2 Web Portal ......................................................................................................... 137 9.3.3 Managed File Transfer (MOVEit) ..................................................................... 137 9.4 Acknowledgement and Error Reports ............................................................... 138 9.4.1 Confirmation Report.......................................................................................... 138 9.4.2 Interchange Level Errors and TA1 Rejection Report ........................................ 138 9.4.3 999 Implementation Acknowledgements .......................................................... 139 9.4.3.1 9.4.4 9.5 9.5.1 9.6 Batch and Real-Time Usage .......................................................................... 139 Data Retrieval Method ...................................................................................... 140 Testing ............................................................................................................... 140 Testing Requirements ........................................................................................ 140 270/271 Eligibility Request and Response ........................................................ 141 9.6.1 ISA Interchange Control Header ....................................................................... 141 9.6.2 GS Functional Group Header ............................................................................ 142 9.6.3 The Following are Access Methods Supported by Wyoming Medicaid ........... 142 9.6.4 270 Eligibility Request ...................................................................................... 143 9.6.5 271 Eligibility Response ................................................................................... 143 9.7 276/277 Claim Request and Response .............................................................. 143 9.7.1 ISA Interchange Control Header ....................................................................... 143 9.7.2 GS Functional Group Header ............................................................................ 143 9.7.3 276 Claim Status Request.................................................................................. 144 Ch. 9 Index 132 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.7.4 9.8 277 Claim Status Response ............................................................................... 144 278 Request for Review and Response ............................................................. 144 9.8.1 ISA Interchange Control header ........................................................................ 144 9.8.2 GS Functional Group Header ............................................................................ 145 9.8.3 278 Prior Authorization Request – Data Clarifications Inbound ...................... 145 9.8.4 X12N 278 Health Care Services Review – Response to Request for Review – Outbound for Wyoming Medicaid .................................................................... 145 9.9 9.9.1 9.10 835 Claim Payment/Advice............................................................................... 145 Payment/Advice ................................................................................................ 145 837 Professional Claims Transactions Wyoming Medical Professional Claims ........................................................................................................................... 146 9.10.1 ISA Interchange Control Header ....................................................................... 146 9.10.2 GS Functional Group Header ............................................................................ 146 9.10.3 837 Professional ................................................................................................ 147 9.11 837 Institutional Claims Transactions Wyoming Medicaid Institutional Claims ........................................................................................................................... 150 9.11.1 ISA Interchange Control header ........................................................................ 150 9.11.2 GS Functional Group Header ............................................................................ 151 9.11.3 837 Institutional ................................................................................................. 151 9.12 837 Dental Claims Transactions Wyoming Medicaid Dental Claims .............. 151 9.12.1 ISA Interchange Control Header ....................................................................... 152 9.12.2 GS Functional Group Header ............................................................................ 152 9.12.3 Dental ................................................................................................................ 152 Ch. 9 Index 133 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.1 Wyoming Specific HIPAA 5010 Electronic Specifications This chapter is intended for trading partner use in conjunction with the ASC X12N Standards for Electronic Data Interchange Technical Report Type 3 (TR3). The TR3 can be accessed at http://www.wpc-edi.com. This section outlines the procedures necessary for engaging in Electronic Data Interchange (EDI) with the Xerox Government Healthcare Solutions EDI Clearinghouse (EDI Clearinghouse) and specifies data clarification where applicable. 9.2 Transaction Definitions 270/271 – Health Care Eligibility Benefit Inquiry and Response. 276/277 – Health Care Claim Status Request and Response. 278/278 – Health Care Services – Request for Review and Response; Health 9.3 Care Services Notification and Acknowledgement. 835 – Health Care Claim Payment/Advice. 837 – Health Care Claim (Professional, Institutional, and Dental), including Coordination of Benefits (COB) and Subrogation Claims. Acknowledgement Transaction Definitions. TA1 – Interchange Acknowledgement. 999 – Implementation acknowledgement for Health Care Insurance . 277CA – Health Care Claim Acknowledgement. Transmission Methods and Procedures 9.3.1 Asynchronous Dial-up The Host System is comprised of communication (COMM) servers with modems. Trading partners access the Host System via asynchronous dial-up. The COMM machines process the login and password, then log the transmission. The Host System will forward a confirmation report to the trading partner providing verification of file receipt. It will show a unique file number for each submission. The COMM machines will also pull the TA1s and 999s from an outbound transmission table, and deliver to the HIPAA BBS Mailbox system. The trading partner accesses the mailbox system via asynchronous dial-up to view and/or retrieve their responses. Ch. 9 Index 134 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.3.1.1 Communication Protocols The EDI Clearinghouse currently supports the following communication options: 9.3.1.2 XMODEM YMODEM ZMODEM KERMIT Teleprocessing Requirements The general specifications for communication with EDI Clearinghouse are: Telecommunications: Hayes-compatible 2400-56K BPS asynchronous modem File Format: ASCII text data Compression Techniques – EDI Clearinghouse accepts transmission with any of these compression techniques, as well as non-compression: o PKZIP will compress one (1) or more files into a single ZIP archive. o WINZIP will compress one (1) or more files into a single ZIP archive. Data Format: o 8 data bit o 1stop bit o no parity o full duplex 9.3.1.3 Teleprocessing Settings ASCII Sending o Send line ends with line feeds (should not be set) o Echo typed characters locally (should not be set) o Line delay 0 millisecond o Character delay 0 milliseconds ASCII Receiving o Append line feeds to incoming line ends should not be checked o Wrap lines that exceed terminal width o Terminal Emulation VT100 or Auto Ch. 9 Index 135 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.3.1.4 Transmission Procedures SUBMITTER Dials Host 1(800) 334-2832 or (800) 334-4650 HOST Answers call, negotiates a common baud rate, and sends to the Trading Partner: Prompt: “Please enter provider Logon=>” Enters User Name (From the EDI Welcome Letter)Receives User Name and sends prompt to the Trading Partner: Prompt: “Please enter provider password=>” Receives Password/User ID and verifies if Trading Partner is an authorized user. Sends HOST selection menu followed by a user prompt: Enters Password/User ID (From the EDI Welcome Letter) Prompt: “Please Select from the Menu Options Below=>” Enters Desired Selection #1. Electronic File Submission: Assigns and sends the transmission file name then waits for ZMODEM (by default) file transfer to be initiated by the Trading Partner. #2. View Submitter Profile #3. Select File Transfer Protocol: Allows the provider to change the protocol for the current submission only. The protocol may be changed to (k) ermit, (x) Modem, (y) Modem, or (z) Modem. Enter selection [k, x, y, z]: #4. Download Confirmation #9. Exit & Disconnect: Terminates connection. Enters “1” to send file Receives ZMODEM (or other designated protocol) file transfer. Upon completion, initiates file confirmation. Sends file confirmation report. Sends HOST selection menu followed by a user prompt=> Prompt: “Please Select from the Menu Options Below=>” Ch. 9 Index 136 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.3.2 Web Portal The trading partner must be an authenticated portal user who is a provider. Only active providers are authorized to access files via the web. Provider must have completed the web registration process. (8.5.2.1, Secured Provider Web Portal Registration Process) Trading partners can submit files via the web portal in two (2) ways: Upload an X12N transaction file – The trading partner accesses the web portal via a web browser and is prompted for login and password. The provider may select files from their PC or work environment and upload files. Enter X12N data information through a web interface – The trading partner accesses the web portal via a web browser and is prompted for login and password. Data entry screens will display for entering transaction information. NOTE: Providers can retrieve their response files via the web portal by logging in and accessing their transaction folders. Transaction files can be uploaded and downloaded through the Secured Provider Web Portal at http://wymedicaid.acs-inc.com. Transaction transmission is available 24-hours a day, seven (7) days a week. This availability is subject to scheduled and unscheduled host downtime. 9.3.3 Managed File Transfer (MOVEit) EDI Clearinghouse supports Managed File Transfer using a product suite called MOVEit. In the diagram below, trading partners can deliver files to or retrieve files from the MOVEit DMZ site. EDI Clearinghouse does corresponding pickups from and deliveries to the DMZ via an agreed upon schedule with Medicaid and trading partner. Ch. 9 Index 137 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.4 Acknowledgement and Error Reports The following acknowledgement reports are generated and delivered to trading partners: TA1 – Will be used to report invalid Trading Partner Relationship Validation to Provider/Trading Partner. 999 – Will be used to acknowledge Syntax Validation (Positive, Negative or Partial) – to Provider/Trading Partner. 277CA – Claims Acknowledgement will be used to provide accept/reject information regarding submitted claims/request – to Provider/Trading Partner. 9.4.1 Confirmation Report When a trading partner submits an X12N transaction, a receipt is immediately sent to the trading partner to confirm that EDI Clearinghouse received a file, and shows a unique file number for each submission. The Host System will forward a Confirmation Report to the trading partner indicating: Verification of file receipt. If the file is accepted or rejected. Identified as an X12N at a high level. If a file fails this preliminary check, it will not continue processing. The Confirmation Report includes the following information: 9.4.2 Date and time file was received File number Payer code (Wyoming Medicaid 77046) Submission format Type of transaction Number of claims and batches Status of Production or Test Additional messages that can be added as a communication to trading partners or may indicate the reason the file is invalid. Interchange Level Errors and TA1 Rejection Report A TA1 is an ANSI ASC X12N Interchange Acknowledgement segment used to report receipt of individual interchange envelopes. An interchange envelope contains the sender, receiver, and data type information within the header. The term "interchange" connotes the ISA/IEA envelope that is transmitted between trading/business partners. Interchange control is achieved through several "control" components. Refer to the TR3 documents for a description of Envelopes and Control Structures. Ch. 9 Index 138 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ The TA1 reports the syntactical analysis of the interchange header and trailer. The TA1 allows EDI Clearinghouse to notify the trading partner that a valid X12N transaction envelope was received; or if problems were encountered with the interchange control structure or the trading partner relationship. The TA1 is unique in that it is a single segment transmitted without the GS/GE envelope structure. If the data can be identified, it is then checked for trading partner relationship validation. If the trading partner information is invalid, the data is corrupt or the trading partner relationship does not exist, a negative confirmation report is returned to the submitter. Any major X12N syntax error that occurs at this level will result in the entire transaction being rejected, and the trading partner will need to resubmit their X12N transaction. If the trading partner information is valid, the data continues processing for complete X12N syntax validation. 9.4.3 999 Implementation Acknowledgements The 999 informs the submitter that the functional group arrived at the destination. It may include information about the syntactical quality of the functional group and the implementation guide compliance. For more information on the relationship between the 999 transaction set and other response transaction sets, refer to the ASC X12N Standards for Electronic Data Interchange Technical Report Type 3 (TR3). The 999 contains information indicating if the entire file is HIPAA 5010 compliant or not. 9.4.3.1 Batch and Real-Time Usage There are multiple methods available for sending and receiving business transactions electronically. Two (2) common modes for EDI transactions are batch and real-time. Batch – In a batch mode the sender does not remain connected while the receiver processes the transactions. Processing is usually completed according to a set schedule. If there is an associated business response transaction (such as a 271 Response to a 270 Request for Eligibility), the receiver creates the response transaction and stores it for future delivery. The sender of the original transmission reconnects at a later time and picks up the response transaction. Real-Time – In real-time mode the sender remains connected while the receiver processes the transactions and returns a response transaction to the sender. Ch. 9 Index 139 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ The 999 contains information indicating if the entire file is HIPAA 5010 compliant or not. 9.4.4 Data Retrieval Method Secured Web Portal The web portal allows all trading partners to retrieve data via the internet 24-hours a day, seven (7) days a week. Each provider has the option of retrieving the transaction responses and reports themselves or allowing billing agents and clearinghouses to retrieve on their behalf. The trading partner will access the Secured Provider Web Portal system using the user ID and password provided upon completion of the enrollment process (8.5.2.1, Secured Provider Web Portal Registration Process). Contact the EDI Services for more information (2.1, Quick Reference). 9.5 Testing Submitters (software vendors, billing agents, clearinghouses, and providers) who have created their own electronic X12 transaction software are required to test their software. Contact EDI Services for more information (2.1, Quick Reference). By testing the submitter is validating their software prior to submitting production transactions. While in test mode for HIPAA 5010 the provider will not be able to submit production files until testing is complete and the providers software is approved. If a production HIPAA 5010 file is submitted while in test mode the file will fail with a TA1 error (9.4.2, Interchange Level Errors and TA1 Rejection Report). 9.5.1 Testing Requirements Contact EDI Services and explain that the provider is ready to test the provider software. Testing via EDIFECS o Submitters cannot obtain direct Internet access to EDIFECS, the EDI Services call center staff will set this up at the provider’s request. o A user ID and password will be generated for the providers use. o The provider is required to submit test files through EDIFECS. o The provider is required to address any errors discovered during testing prior to moving on to testing with the EDI Clearinghouse. o After the provider’s software has received approval provide EDI Services with the EDIFECS certification. Testing with EDI Clearinghouse o The call center will have the provider submit a test file. o After 24-hours contact the call center for test file results. Ch. 9 Index 140 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ o Make corrections based on the TR3s and Wyoming Specific HIPAA 5010 Specifications. o Resubmit test files as necessary. o Successful completion of the testing process is required before a submitter will be approved for production. A separate testing process must be completed for each type of transaction i.e. 270/271, 276/277, 837 etc. Each test transmission is validated to ensure no format errors are present. Testing is conducted to verify the integrity of the format not the integrity of the data. However, in order to simulate a true production environment, we request that test files contain realistic healthcare transaction data. The number of test transmissions required depends on the number of format errors in a transmission and the relative severity of these errors. Additional testing may be required in the future to verify any changes made to Wyoming Specific HIPAA 5010 Specifications or HIPAA mandated changes. 9.6 270/271 Eligibility Request and Response Health Care Eligibility Benefit Inquiry Request and Response for Wyoming Medicaid. This section is for use along with the ANSI ASC X12 Health Care Eligibility Request & Response 270/271. It should not be considered a replacement for the TR3’s, but rather used as an additional source of information. This section contains data clarifications derived from specific business rules that apply exclusively to Wyoming Medicaid. NOTE: 9.6.1 The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Consolidated Guide; Health Care Eligibility Benefit Inquiry and Response for the 270/271 005010X279 & 005010X279A1, June 2010. ISA Interchange Control Header TR3 Page Loop Segment Reference Description Wyoming Requirements Appendix C Page C.5 Header ISA 08 100000 Followed by spaces Ch. 9 Index 141 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.6.2 GS Functional Group Header TR3 Page Loop Segment Reference Description Wyoming Requirements Appendix C page C.7 Header GS 03 Enter 77046 9.6.3 The Following are Access Methods Supported by Wyoming Medicaid Access by Member ID number for subscriber. Access by Member Card ID number. Access by Social Security Number, and Date of Birth (Format CCYYMMDD) for the subscriber. Access by Social Security Number, and Name for the subscriber (Any nonalphanumeric character including spaces that are included in the last name or the first name may cause the inquiry to not be successfully processed). Access by Name (Any non-alphanumeric character including spaces that are included in the last name or the first name may cause the inquiry to not be successfully processed), Sex, and Date of Birth for the subscriber. NOTE: Ch. 9 Index References to “Subscriber” are taken from the ANSI ASC X12N Consolidated Guide; Health Care Eligibility Benefit Inquiry and Response for the 270/271 005010X279 & 005010X279A1 and are synonymous with Member. 142 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.6.4 270 Eligibility Request TR3 Page Loop Segment Page 72 2100A NM1 Reference Description 03 Page 79 2100B NM1 08 Page 80 2100B NM1 09 9.6.5 Wyoming Requirements Wyoming Medicaid NOTE: SV should be used only when a Wyoming Provider is an Atypical Provider/non-medical. NOTE: Enter Wyoming Medicaid Provider ID when NM108 is SV. 271 Eligibility Response No Wyoming Specific Requirements. 9.7 276/277 Claim Request and Response Health Care Claim Status Request and Response for Wyoming Medicaid. This section is for use along with the ANSI ASC X12 Health Care Claim Status Request and Response 276/277. It should not be considered a replacement for the TR3’s, but rather used as an additional source of information. This section contains data clarifications derived from specific business rules that apply exclusively to Wyoming Medicaid. NOTE: 9.7.1 The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Health Care Claim Status Request and Response for the 276/277 005010X212, August 2006. ISA Interchange Control Header TR3 Page Loop Segment Reference Description Appendix C Page C.5 Header ISA 08 9.7.2 Enter 100000 followed by spaces GS Functional Group Header TR3 Page Loop Segment Reference Description Appendix C Page C.7 Header GS 03 Ch. 9 Index Wyoming Requirements 143 Wyoming Requirements Enter 77046 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.7.3 276 Claim Status Request TR3 Page Loop Segment Reference Description Page 46 2100B NM1 09 Page 51 2100C NM1 08 Page 73 2210D REF 01 Page 73 2210D REF 02 9.7.4 Wyoming Requirements NOTE: Enter the nine (9) digit Wyoming Medicaid Provider ID when a Wyoming Provider is an Atypical Provider/non-medical NOTE: SV should be used only when a Wyoming Provider is an Atypical Provider/non-medical. The Line Item Control Number inquiry is not supported by Wyoming Medicaid. The Claim Status Response will return all claim line items. The Line Item Control Number inquiry is not supported by Wyoming Medicaid. The Claim Status Response will return all claim line items. 277 Claim Status Response No Wyoming Specific Requirements. 9.8 278 Request for Review and Response Health Care Services Request for Review/Response for Wyoming Medicaid This section is for use along with the ANSI ASC X12 Health Care Prior Authorization Request and Response 278. It should not be considered a replacement for the TR3’s, but rather used as an additional source of information. This section contains data clarifications derived from specific business rules that apply exclusively to Wyoming Medicaid. NOTE: 9.8.1 The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Health Care Services Review – Request for Review and Response for the (278) 005010X217, May 2006. ISA Interchange Control header TR3 Page Loop Segment Data Element Appendix C Page C.5 Interchange Control Header ISA 08 Ch. 9 Index 144 Wyoming Requirements Enter 100000 followed by spaces Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.8.2 GS Functional Group Header TR3 Page Loop Segment Data Element Appendix C Page C.7 Functional Group Header GS 03 Enter 77046 278 Prior Authorization Request – Data Clarifications Inbound 9.8.3 TR3 Page Loop Segment Page 73 2010A NM1 Data Element 09 Wyoming Requirements Enter 77046 X12N 278 Health Care Services Review – Response to Request for Review – Outbound for Wyoming Medicaid 9.8.4 9.9 Wyoming Requirements 835 Claim Payment/Advice Health Care Claim Payment Advice for Wyoming Medicaid. 9.9.1 TR3 Page Payment/Advice Loop Segment Data Element Page 107 1000B REF 01 108 1000B REF 02 Page 207208 2110 REF 01 Page 208 2110 REF 02 Ch. 9 Index 145 Wyoming Requirements If the provider does not have an NPI then REF01 will contain “PQ” (Payee Identification) and REF02 will contain the Wyoming Medicaid Provider ID. If the provider does not have an NPI then REF01 will contain “PQ” (Payee Identification) and REF02 will contain the Wyoming Medicaid Provider ID. Either HPI or G2 will be displayed. NOTE: G2 will be displayed only for WY Medicaid Atypical Providers. NOTE: Enter the nine (9) digit Wyoming Medicaid Provider ID when a Wyoming Provider is an Atypical/non-medical. Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.10 837 Professional Claims Transactions Wyoming Medical Professional Claims This section is for use along with the ANSI ASC X12 Health Care 837 Claims Transactions. It should not be considered a replacement for the TR3s, but rather used as an additional source of information. This section contains data clarifications derived from specific business rules that apply exclusively to Wyoming Medicaid. NOTE: 9.10.1 TR3 Page Appendix C Page C.3 Appendix C Page C.4 Appendix C Page C.4 Appendix C Page C.5 9.10.2 TR3 Page Appendix C Page C.7 Appendix C Page C.7 Ch. 9 Index The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Consolidated Guide Health Care Claim: Professional (837), 005010X222/005010X222A1, June 2010 ISA Interchange Control Header Loop Segment Reference Description Header ISA 01 Enter 00 Header ISA 03 Enter 00 Header ISA 06 Enter Trading Partner ID Header ISA 08 Enter 100000 followed by spaces Segment Data Element Wyoming Requirements GS 02 Enter Trading Partner ID GS 03 Enter 77046 Wyoming Requirements GS Functional Group Header Loop Functional Group Header Functional Group Header 146 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.10.3 837 Professional TR3 Page Loop Segment Reference Description Page 72 Header BHT 06 Page 80 Page 80 1000B 1000B NM1 NM1 03 09 Page 83 2000A PRV 03 Page 115 2000B HL 04 Page 116-117 2000B SBR 01 Page 123 2010BA NM1 09 Page 134 Page 134 Page 134 2010BB 2010BB 2010BB NM1 NM1 NM1 03 08 09 Page 140 2010BB REF 01 Page 140-141 2010BB REF 02 Ch. 9 Index 147 Wyoming Requirements Wyoming Medicaid only accepts the CH code. Enter Wyoming Medicaid. Enter 77046. If the NPI is registered with Wyoming Medicaid, the Taxonomy Code is required. Enter 0. The subscriber is always the patient; therefore, the dependent level will not be utilized. Enter P (Primary-Payer Responsibility Sequence Number code) Client has only Medicaid Coverage. Enter the ten (10) digit Wyoming Medicaid Client ID. Enter Wyoming Medicaid. Enter PI (Payer Identification). Enter 77046. If ‘XX’ is used to pass the NPI number in 2010AA, NM109, then Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then submit ‘G2’ (Provider Commercial Number) in 2010BB REF01, and submit the Wyoming Medicaid Provider Number in the 2010BB REF02. If ‘XX’ is used to pass the NPI number in 2010AA, NM109, then Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then submit ‘G2’ (Provider Commercial Number) in 2010BB REF01 and submit the Wyoming Medicaid Provider number in 2010BB REF02. Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ TR3 Page Loop Segment Reference Description Page 161 2300 CLM 05:3 Page 262-263 2310A REF 01 Page 262-263 2310A REF 02 Page 269-270 2310B REF 01 Ch. 9 Index 148 Wyoming Requirements Void/Adjustment (Frequency Type Code) should be six (6) (Adjustment) only if paid date was within the last six (6) months (12-month timely filing will be waived), or seven (7) (Void/Replace) which is subject to timely filing. Adjustments can only be submitted on a previously paid claim. Do not adjust a denied claim. For nonadjustment options see the TR3. If ‘XX’ is used to pass the NPI Number in NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in REF01 and the Wyoming Medicaid Provider ID in REF02. If ‘XX’ is used to pass the NPI number in NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in the REF01 and the Wyoming Medicaid Provider ID in REF02. If ‘XX’ is used to pass the NPI number in NM10, then Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in REF01 and the Wyoming Medicaid Provider ID in REF02. Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ TR3 Page Loop Segment Reference Description Page 269-270 2310B REF 02 Page 300 2320 SBR 09 Page 427 2410 LIN 03 Page 436 2420A PRV 03 Page 437 Ch. 9 Index 2420A REF 01 149 Wyoming Requirements If ‘XX’ is used to pass the NPI number in NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted the enter ‘G2’ (Provider Commercial Number) in REF01 and the Wyoming Medicaid Provider ID in REF02. Do not use code MC. Enter the 11 digit National Drug Code (NDC). NDC’s less than 11-digits will cause the service line to be denied by Wyoming Medicaid. Do not enter hyphens or spaces within the NDC. NOTE: Only the first iteration of Loop 2410 will be used for claims processing. If two (2) or more NDCs need to be reported for the same procedure code on the same claim, the procedure code must be repeated on a separate service line with the first iteration of Loop 2410 used to report each unique NDC. For more information consult the Wyoming Medicaid website (http://wymedicaid.acs-inc.com). If the NPI is registered with Wyoming Medicaid, the Taxonomy Code is required. If ‘XX’ is used to pass the NPI number in NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in REF01 and the Wyoming Medicaid Provider ID in REF02. Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ TR3 Page Loop Segment Reference Description Page 471 2420 F REF 01 Page 472 2420F REF 02 Wyoming Requirements If ‘XX’ is used to pass the NPI number in NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in REF01 and the Wyoming Medicaid Provider ID in REF02. If ‘XX’ is used to pass the NPI number is NM109, Medicaid Provider Number is no longer allowed, do not submit this segment. If no NPI was submitted then enter ‘G2’ (Provider Commercial Number) in REF01 and Wyoming Medicaid Provider ID in REF02. 9.11 837 Institutional Claims Transactions Wyoming Medicaid Institutional Claims This section is for use along with the ANSI ASC X12 Health Care 837 Claims Transactions. It should not be considered a replacement for the TR3s, but rather used as an additional source of information. This section contains data clarifications derived from specific business rules that apply exclusively to Wyoming Medicaid. NOTE: 9.11.1 TR3 Page Appendix C Page C.4 Appendix C Page C.5 Ch. 9 Index The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Consolidated Guide Health Care Claim: Institutional (837), 005010X223/005010X223A/1005010X223A2, June 2010. ISA Interchange Control header Loop Segment Reference Description Header ISA 06 Enter Trading Partner ID Header ISA 08 Enter 100000 followed by spaces 150 Wyoming Requirements Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.11.2 GS Functional Group Header TR3 Page Loop Segment Data Element Appendix C Page C.7 Functional Group Header GS 02 Enter Trading Partner ID Appendix C Page C.7 Functional Group Header GS 03 Enter 77046 9.11.3 Wyoming Requirements 837 Institutional TR3 Page Loop Segment Reference Description Page 77 1000B NM1 03 Enter Wyoming Medicaid Page 77 1000B NM1 09 Page 147 2300 CLM 05:3 Enter 77046 Void/Adjustment (Frequency Type Code) should be 6 (Adjustment) only if paid date was within the last six (6) months (12 month timely filing will be waived), or seven (7) (Void/Replace) which is subject to timely filing. Adjustments can only be submitted on a previously paid claim. Do not adjust a denied claim. For non-adjustment options see the TR3. Wyoming Requirements 9.12 837 Dental Claims Transactions Wyoming Medicaid Dental Claims NOTE: Ch. 9 Index The page numbers listed below in each of the tables represent the corresponding page number in the Technical Report Type3 (TR3) ANSI ASC X12N Consolidated Guide Health Care Claim: Dental (837), 005010X224/005010X224A1/005010X224A2, June 2010. 151 Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ 9.12.1 TR3 Page Appendix C Page C.4 Appendix C Page C.5 9.12.2 ISA Interchange Control Header Loop Segment Reference Description Header ISA 06 Enter Trading Partner ID Header ISA 08 Enter 100000 followed by spaces GS Functional Group Header TR3 Page Loop Appendix C Page C.7 Appendix C Page C.7 Functional Group Header Functional Group Header 9.12.3 Wyoming Requirements Segment Data Element Wyoming Requirements GS 02 Enter Trading Partner ID GS 03 Enter 77046 Dental TR3Page Loop Segment Page 75 Page 75 Page 125 1000B 1000B 2010BB NM1 NM1 NM1 Reference Description 03 09 03 Page 125 2010BB NM1 08 Enter PI (Payor Identification) Page 125 Page 126 Page 127 Page 128 Page 128 2010BB 2010BB 2010BB 2010BB 2010BB NM1 N3 N4 N4 N4 09 01 01 02 03 Enter 77046 Enter PO Box 547 Enter Cheyenne Enter WY Enter 82003 Ch. 9 Index 152 Wyoming Requirements Enter Wyoming Medicaid Enter 77046 Enter Wyoming Medicaid Revision 4/1/17 Wyoming Specific HIPAA_5010 Electronic Specifications_____________________________ TR3Page Page 149 Ch. 9 Index Loop 2300 Segment Reference Description Wyoming Requirements 05:3 Void/Adjustment (Frequency Type Code) should be six (6) (Adjustment) only if paid date was within the last six (6) months (12 month timely filing will be waived), or seven (7) (Void/Replace) which is subject to timely filing. Adjustments can only be submitted on a previously paid claim. Do not adjust a denied claim. For non-adjustment options see the TR3. CLM 153 Revision 4/1/17 Important Information__________________________________________________________ Chapter Ten – Important Information 10.1 Claims Review .................................................................................................. 155 10.2 Physician Supervision Definition ...................................................................... 155 10.3 Coding ............................................................................................................... 155 10.4 Importance of Fee Schedules and Provider’s Responsibility ............................ 156 10.5 Face-to-Face Visit Requirement ........................................................................ 156 Ch. 10 Index 154 Revision 4/1/17 Important Information__________________________________________________________ 10.1 Claims Review Medicaid is committed to paying claims as quickly as possible. Claims are electronically processed using an automated claims adjudication system and are not usually reviewed prior to payment to determine whether the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims that it cannot detect. For this reason, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and Medicaid later discovers the service was incorrectly billed or paid, or the claim was erroneous in some other way, Medicaid is required by federal regulations to recover any overpayment, regardless of whether the incorrect payment was the result of Medicaid, fiscal agent, provider error or other cause. 10.2 Physician Supervision Definition Supervision is defined as the ready availability of the supervisor for consultation and direction of the individual providing services. Contact with the supervisor by telecommunication is sufficient to show ready availability, if such contact is sufficient to provide quality care. The supervising practitioner maintains final responsibility for the care of the client and the performance of the mental health professional in their office. Supervisor is defined as an individual licensed to provide services who takes professional responsibility for such services, even when provided by another individual or individuals. The physical presence of the supervisor is not required if the supervisor and the practitioner are, or can easily be, in contact with each other by telephone, radio, or other telecommunications. The supervised individual may work in the office of the supervisor where the primary practice is maintained and at sites outside that office as directed by the supervisor. Fiscal responsibility and documentation integrity for claims remains with the supervisor. Those provider types able to enroll with Wyoming Medicaid, even if working under the supervision of another practitioner, must enroll and be noted on the claim as the rendering provider. 10.3 Coding Standard use of medical coding conventions is required when billing Medicaid. Provider Relations or the Division of Healthcare Financing cannot suggest specific Ch. 10 Index 155 Revision 4/1/17 Important Information__________________________________________________________ codes to be used in billing services. The following suggestions may help reduce coding errors and unnecessary claim denials: Use current CPT-4, HCPCS Level II, and ICD-9-CM/ICD-10 coding books. NOTE: The DSM-V, while useful for diagnostic purposes, is not considered a coding manual, and should be used only in conjunction with the above. Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing. Attend coding classes offered by certified coding specialists. Use the correct unit of measurement. In general, Medicaid follows the definitions in the CPT-4 and HCPCS Level II coding books. One (1) unit may equal “one (1) visit” or “15 minutes.” Always check the long version of the code description. Effective April 1, 2011, the National Correct Coding Initiative (NCCI) methodologies were incorporated into Medicaid’s claim processing system in order to comply with Federal legislation. The methodologies apply to both CPT Level I and HCPCS Level II codes. Coding denials cannot be billed to the patient but can be reconsidered per Wyoming Medicaid Rules, Chapter 16. Send a written letter of reconsideration to Wyoming Medicaid, Medical Policy (2.1, Quick Reference). 10.4 Importance of Fee Schedules and Provider’s Responsibility Procedure codes listed in the following sections are subject to change at any time without prior notice. The most accurate way to verify coverage for a specific service is to review the Medicaid fee schedules on the website (2.1, Quick Reference). Fee schedules list Medicaid covered codes, provide clarification of indicators such as whether a code requires prior authorization and the number of days in which followup procedures are included. Not all codes are covered by Medicaid or are allowed for all taxonomy codes (provider types). It is the provider’s responsibility to verify this information. Use the current fee schedule in conjunction with the more detailed coding descriptions listed in the current CPT-4 and HCPCS Level II coding books. Remember to use the fee schedule and coding books that pertain to the appropriate dates of service. 10.5 Face-to-Face Visit Requirement For practitioners ordering new Durable Medical Equipment (DME) or Prosthetic/Orthotic Supplies (POS) for a client, the client must have a face-to-face visit related to the condition for which the item(s) are being ordered within the previous six (6) months with the ordering or prescribing practitioner. The supplying Ch. 10 Index 156 Revision 4/1/17 Important Information__________________________________________________________ provider will need the date and the name of the practitioner with whom the face-toface visit occurred for their records in order to bill Wyoming Medicaid for the DME or POS supplied. Note: This requirement is waived for renewals of existing DME or POS orders. Ch. 10 Index 157 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ Chapter Eleven – Covered Services – Ambulance 11.1 Ambulance Services .......................................................................................... 159 11.2 Covered Services ............................................................................................... 159 11.2.1 Emergency Transportation ................................................................................ 159 11.2.2 Non-Emergency Transportation ........................................................................ 160 11.2.3 Definitions of Service Levels ............................................................................ 160 11.3 Disposable Supplies .......................................................................................... 161 11.4 Oxygen and Oxygen Supplies ........................................................................... 161 11.5 Mileage .............................................................................................................. 162 11.6 Non-covered Services........................................................................................ 162 11.7 Multiple Client Transportation .......................................................................... 163 11.8 Usual and Customary Charge ............................................................................ 163 11.9 Billing Requirements ......................................................................................... 164 Ch. 11 Index 158 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ 11.1 Ambulance Services Ambulance providers are independent ambulances or hospital-based ambulances. Medicaid covers ambulance transports, with medical intervention, by ground or air to the nearest appropriate facility. An appropriate facility is considered an institution generally equipped to provide the required treatment for the illness or injury involved. Each ambulance service provided to a client (transport, life support, oxygen, etc.) must be medically necessary to be covered by Medicaid. Procedure Code Range: A0380-A0436 11.2 Covered Services 11.2.1 Emergency Transportation Medicaid covers emergency transportation by either Basic Life Support or Advanced Life Support ambulance under the following conditions: A medical emergency exists in that the use of any other method of transportation could endanger the health of the patient; and The patient is transported to the nearest facility capable of meeting the patient’s medical needs; and The destination is an acute care hospital where the patient is admitted as an inpatient or outpatient. For purposes of this section, a medical emergency is considered to exist under any of the following circumstances: An emergency situation, due to an accident, injury, or acute illness; or Restraints are required to transport the patient (often when a psychiatric Ch. 11 Index diagnosis is made); or The patient is unconscious or in shock; or Immobilization is required due to a fracture of the possibility of a fracture; or The patient is experiencing symptoms of myocardial infarction or acute stroke; or The patient is experiencing severe hemorrhaging. 159 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ 11.2.2 Non-Emergency Transportation Non-emergency transportation is covered when any other mode of transportation would endanger the health or life of a client and at least one (1) of the following criteria is met: Continuous dependence on oxygen. Continuous confinement to bed. Cardiac disease resulting in the inability to perform any physical activity 11.2.3 without discomfort. Receiving intravenous treatment. Heavily sedated. Comatose. Post pneumo/encephalogram, myelogram, spinal catheterization. Hip spicas and other casts that prevent flexion at the hip. Requirement for isolette in perinatal period. State of unconsciousness or semi-consciousness. tap, or cardiac Definitions of Service Levels Basic Life Support Services – A Basic Life Support (BLS) ambulance is one which provides transportation in addition to the equipment, supplies, and staff required for basic services such as the control of bleeding, splinting of fractures, treatment for shock, and basic cardiopulmonary resuscitation (CPR). Basic Life Support – Emergency – Basic Life Support emergency services must meet one (1) of the criteria listed under Emergency Transportation and the definition of Basic Life Support Services. Basic Life Support Services – Non-Emergency – Basic Life Support nonemergency services must meet one (1) of the criteria listed under Non-Emergency Transportation and the definition of Basic Life Support Services. Advanced Life Support Services – Advanced Life Support (ALS), means treatment rendered by highly skilled personnel, including procedures such as cardiac monitoring and defibrillation, advanced airway management, intravenous therapy and/or the administration of certain medications. Advanced Life Support Level 1 – Emergency (ALS1-emergency) – This level of service is transportation by ground ambulance with provision for medically necessary supplies, oxygen, and at least one (1) ALS intervention. The ambulance and its crew must meet certification standards for ALS care. An ALS intervention refers to the provision of care outside the scope of an EMT-basic and must be medically necessary (e.g. medically necessary EKG monitoring, drug administration, etc.) An ALS assessment does not necessarily result in a determination that the client requires an ALS level of service. Ch. 11 Index 160 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ Advanced Life Support Level 1 – Non-Emergent (ALS1 non-emergent) – This level of service is the same as ALS1-emergency but in non-emergent circumstances. Advanced Life Support Level 2 (ALS2) – Covered for the provision of medically necessary supplies and services including: 1. At least three (3) separate administrations of one (1) or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids); or 2. Ground ambulance transport, medically necessary supplies and services, and the provision of at least one (1) of the ALS2 procedures listed below: Manual defibrillation/cardio version. Endotracheal intubation. Central venous line. Cardiac pacing. Chest decompression. Surgical airway. Intraosseous line. Air Ambulance Services – Medicaid covers both conventional air and helicopter ambulance services. These services are only covered under the following conditions: The client has a life threatening condition which does not permit the use of another form of transportation; or The client’s location is inaccessible by ground transportation; or Air transport is more cost effective than any other alternative. Medicaid covers air ambulance transfers of a client who is discharged from one (1) inpatient facility and transferred and admitted to another inpatient facility when distance or urgency precludes the use of ground ambulance. 11.3 Disposable Supplies Medicaid covers disposable and non-reusable supplies such as gauze and dressings, defibrillation supplies, and IV drug therapy disposable supplies. When medically necessary, each service is allowed to be billed up to five (5) units. 11.4 Oxygen and Oxygen Supplies Medicaid covers oxygen and related disposable supplies only when the client’s condition at the time of transport requires oxygen. Medicaid does not cover oxygen when it is provided only on the basis of protocol. Ch. 11 Index 161 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ 11.5 Mileage Although mileage may be billed in addition to the base rate for ground transport, it is only paid for loaded miles (client on board) from pickup to destination. Loaded mileage is covered in addition to the base rate for all air transports. Mileage must be medically necessary, which means that mileage should equal the shortest route to the nearest appropriate facility. Exceptions may occur such as road construction or weather. When billing for mileage, one (1) unit is equal to one (1) statute (map) mile for both air and ground transport. Mileage must be rounded to the nearest mile. 11.6 Non-covered Services Medicaid does not reimburse for the following ambulance services: Transportation to receive services that are not covered services. No-load trips and unloaded mileage (when no patient is aboard the Ch. 11 Index ambulance), including transportation of life-support equipment in response to an emergency call. Transportation of a client who is pronounced dead before an ambulance is called. When a client is pronounced dead after an ambulance is called but before transport. Transportation of a family member or friend to visit a client or consult with the client’s physician or other provider of medical services. Transportation to pick up pharmaceuticals. A client’s return home when ambulance transportation is not medically necessary or a client’s return back to a nursing facility. Transportation of a resident of a nursing facility to receive services that are available at the nursing facility. Transportation to a mental health facility if no other appropriate ambulance criteria is met. Air ambulance services to transport a client from a hospital capable of treating the client to another hospital because the client or family prefers a specific hospital or practitioner. Transportation of a client in response to detention ordered by a court or law enforcement agency. Transportation based on a physician’s standing orders. Stand-by time. Special attendants. Specialty Care Transport (SCT). Paramedic Intercept (PI). 162 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ When a client can be transported by a mode other than ambulance without endangering the client’s health, regardless of whether other transportation is available. If a client is an inpatient at a hospital, Medicaid does not pay separately for round trip ambulance transport for an outpatient service (e.g., e-ray or other procedure) at a different hospital. This type of transport is included in the Medicaid payment to the hospital for the inpatient stay. Transportation of a client having suicidal ideations, if no other appropriate ambulance criteria is met. Transports related to Emergency/Involuntary Detainment/Title 25. 11.7 Multiple Client Transportation When more than one (1) client is transported during the same trip, Medicaid will cover one (1) base rate and one (1) mileage charge per transport, not per client. Medicaid will reimburse for each client’s supplies and oxygen. 11.8 Usual and Customary Charge Providers should bill Medicaid their usual and customary charge for each service; that is, the same charge that would be billed to other payers for that service. Ch. 11 Index 163 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ 11.9 Billing Requirements The following are the procedure codes accepted for ambulance services: Procedure Description Code GROUND/Basic Life Support (BLS) A0380 BLS mileage (per mile) A0382 BLS routine disposable supplies Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining A0422 situation A0425 Ground mileage, per statute mile A0428 Ambulance service, basic life support, non-emergency transport, (BLS) Ambulance service, basic life support, emergency transport (BLS, A0429 emergency) GROUND/Advanced Life Support (ALS) A0390 ALS mileage (per mile) A0398 ALS routine disposable supplies Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining A0422 situation A0425 Ground mileage, per statute mile Ambulance service, advanced life support, non-emergency transport, level 1 A0426 (ALS1) Procedure Code Description Ambulance service, advanced life support, emergency transport, level 1 A0427 (ALS1-emergency) A0433 Advanced life support, level 2 (ALS 2) Air Ambulance Ambulance service, conventional air services, transport, one (1) way (fixed A0430 wing) Ambulance services, conventional air services, transport, one (1) way (rotary A0431 wing) A0435 Fixed wing air mileage, per statute mile A0436 Rotary wing air mileage, per statute mile Wyoming Medicaid does not require a separate trip report provided the request for service has been entered appropriately into the Wyoming Ambulance Trip Reporting System (WATRS https://health.wyo.gov/publichealth/ems/watrs/), and marked appropriately for Wyoming Medicaid to review. In order for Wyoming Medicaid to be able to view the report, EMS providers or billing agents must select either the "Primary Method of Payment" or "Insurance Company Name" as Wyoming Medicaid. Both of these data elements are in the Billing section of WATRS. Failure to select the proper data element will prohibit Ch. 11 Index 164 Revision 4/1/17 Covered Services - Ambulance___________________________________________________ Wyoming Medicaid staff from being able to review your entered information, and your claim will be denied for not having a Trip Report. Effective June 1, 2017 Wyoming Medicaid will no longer accept paper trip reports for any billed claim, and will only review the data entered into WATRS. Please see the Rules and Regulations for Wyoming Emergency Medical Services W.S. 33-36-101 through -115 Chapter 4, Section 4 for reporting requirements. The WATRS reporting requirements apply if: The call originates in Wyoming and ends in Wyoming. (e.g. Wyoming Wyoming) If the ambulance itself starts in Wyoming, goes somewhere out of state and comes back to Wyoming. (e.g. Wyoming - Denver - Wyoming.) If the ambulance itself starts in Wyoming, goes somewhere out of state and ends out of state. (e.g. Wyoming - Denver - Salt Lake.) Transports that do not touch ground in Wyoming at any point will still be permitted to submit paper trip reports. If submitting a paper trip report, the claim should be submitted through the usual electronic billing method, and the claim should indicate that an attachment will be coming and by what method, electronic or mail (6.15, Submitting Attachments for Electronic Claims). The paper trip report must include the following: Documentation in the narrative to support the level of service billed Ch. 11 Index (ALS/BLS, Emergent/Non-Emergent, and if air transport rotary/fixed wing). Documentation in the narrative to support the medical necessity of the transport. Documentation in the narrative of the use and medical necessity of any supplies. Documentation in the narrative of the use and medical necessity of any oxygen. Documentation of the patient loaded miles (must match the number of units billed on the claim). 165 Revision 4/1/17 Covered Services – Audiology____________________________________________________ Chapter Twelve – Covered Services – Audiology 12.1 Audiology Services ........................................................................................... 167 12.2 Requirements ..................................................................................................... 167 12.3 Reporting Standards .......................................................................................... 167 12.4 Billing Procedures ............................................................................................. 168 12.5 Reimbursement .................................................................................................. 169 12.6 Hearing Aid Repair ........................................................................................... 169 12.7 Hearing Aid Insurance....................................................................................... 169 Ch. 12 Index 166 Revision 4/1/17 Covered Services – Audiology____________________________________________________ 12.1 Audiology Services Audiology Services – A hearing aid evaluation (HAE) and basic audio assessment (BAA) provided by a licensed audiologist, upon a licensed practitioner referral, to individuals with hearing disorders. Hearing Aid – An instrument or device designed for or represented as aiding or improving defective human hearing and includes the parts, attachments or accessories of the instrument or device. Hearing Aid Dispenser – A person holding an active license to engage in selling, dispensing, or fitting hearing aids. Procedure Code Range: V5000-V5275 and 92550-92700 12.2 Requirements Clients must be referred by a licensed practitioner. The practitioner must indicate on the referral there is no medical reason for which a hearing aid would not be appropriate in correcting the client’s hearing loss. Written orders from the licensed practitioner, diagnostic reports and evaluation reports must be current and available upon request. Basic Audio Assessment (BAA) under earphones in a sound attenuated room must include, at a minimum, speech discrimination tests, speech reception thresholds, pure tone air thresholds, and either pure tone bone thresholds or tympanometry, with acoustic reflexes. Hearing Aid Evaluation (HAE) includes those procedures necessary to determine the acoustical specifications most appropriate for the individual’s hearing loss. 12.3 Reporting Standards The audiologist’s report for Medicaid clients must contain the following information: The client’s name, date of birth, and Medicaid ID number; Results of the audiometric tests at 500, 1,000, 2,000, and 3,000 hertz for the right and left ears, and the word recognition or speech discrimination scores obtained at levels which insure pb max; The report shall include the audiologist’s name, address, license number, and signature of the audiologist completing the audiological evaluation, including the date performed; and A written summary from the licensed audiologist regarding the results of the evaluation indicating whether a hearing instrument is required, the type of hearing instrument (e.g., in-the-ear, behind-the-ear, body amplifier, etc.), and whether monaural or binaural aids are requested. Ch. 12 Index 167 Revision 4/1/17 Covered Services – Audiology____________________________________________________ A copy must be sent to the referring practitioner for the client’s permanent record. If binaural aids are requested, all of the following criteria must be met: Two-frequency average at 1 KHZ and 2 KHZ must be greater than 40 decibels in both ears; Two-frequency average at 1 KHZ and 2 KHZ must be less than 90 decibels in both ears; Two-frequency average at 1 KHZ and 2 KHZ must have an interaural difference of less than 15 decibels; Interaural word recognition or speech discrimination score must have a difference of not greater than 20%; Demonstrated successful use of a monaural hearing aid for at least six (6) months; and Documented need to understand speech with a high level of comprehension based on an educational or vocational need. A hearing aid purchased by Medicaid will be replaced no more than once in a five (5) year period unless: The original hearing aid has been irreparably broken or lost after the one (1)year warranty period; The provider’s records document the loss or broken condition of the original hearing aid; and The hearing loss criteria specified in this rule continues to be met; or The original hearing aid no longer meets the needs of the client and a new hearing aid is determined to be medically necessary by a licensed audiologist. The audiologist should provide a copy of the report to the Medicaid client to take to the hearing aid dispenser (if the audiologist is not the provider for the hearing aid). The audiologist retains the original report in the client’s medical file. 12.4 Billing Procedures Providers must bill for services using the procedure codes set forth and according to the definitions contained in the HCPCS Level II and CPT coding book. Providers are responsible for billing services provided within the scope of their practice and licensure. It is essential for providers to have the most current HCPCS and CPT editions for proper billing. The date of service is the date the hearing aid is delivered or the date that the repairs are completed. A copy of the invoice must be attached to the claim. No other attachments are required (6.15, Submitting Attachments for Electronic Claims). Ch. 12 Index 168 Revision 4/1/17 Covered Services – Audiology____________________________________________________ The provider bills Medicaid for hearing aids using two (2) separate procedure codes; one (1) for the hearing aid and one (1) for the dispensing fee. The hearing aid must be billed under the appropriate procedure code(s). 12.5 Reimbursement Medicaid payment for audiology services will be based on the Medicaid fee schedule. Medicaid reimburses for hearing aids either by fee schedule or invoice plus shipping plus 15%. The dispensing fee is payable on the day the hearing aid was delivered. NOTE: 12.6 These fees are subject to change. The most accurate way to verify coverage for a specific service is to review the Medicaid fee schedule on the website (2.1, Quick Reference). Hearing Aid Repair The following guidelines apply to the repair of hearing aids: Repairs covered under warranty are not billable to Medicaid. V5014 is used to bill for repairs that are not covered under warranty. Re-dispensing fees may be applicable. When re-dispensing the hearing aid after the repair, use the RP modifier with the appropriate dispensing code. Claims must have an invoice attached. Claims are reimbursed at invoice plus shipping only 12.7 Hearing Aid Insurance Hearing aid insurance is covered for services not covered under warranty or when the warranty expires. Use the following codes: X5612 Standard hearing aid insurance, per aid, annual fee. X5613 Advanced hearing aid insurance, per aid, annual fee. Ch. 12 Index 169 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Chapter Thirteen – Covered Services – Behavioral Health 13.1 Behavioral Health Services ............................................................................... 172 13.2 Requirements for Community Mental Health Centers (CMHC) and Substance Abuse Centers.................................................................................................... 172 13.2.1 Provider’s Role .................................................................................................. 173 13.2.2 Responsibilities of Mental Health/Substance Abuse Providers ........................ 173 13.2.3 Qualification for Participating Provider and Staff ............................................ 174 13.3 Covered Services for Community Mental Health and Substance Abuse Treatment Centers ............................................................................................. 175 13.3.1 Rehabilitative Option Services .......................................................................... 175 13.3.2 Targeted Case Management .............................................................................. 177 13.3.3 EPSDT Mental Health Services or Ongoing Case Management ...................... 177 13.3.4 Limitations to Mental Health/Substance Abuse Services ................................. 178 13.3.5 Quality Assurance ............................................................................................. 178 13.4 13.4.1 13.5 13.5.1 Community Mental Health & Substance Abuse Treatment Centers Billing Procedures ......................................................................................................... 179 Psychiatric Services ........................................................................................... 179 Eligible Providers .............................................................................................. 189 Psychiatric Services ........................................................................................... 191 13.5.1.1 Psychologists ................................................................................................. 192 13.5.1.2 Licensed Mental Health Professionals .......................................................... 192 13.5.1.3 Provisional Licensed Mental Health Professionals ....................................... 192 13.5.1.4 Supervision .................................................................................................... 193 13.5.2 Behavioral Health Providers Eligible for Medicare Enrollment ....................... 193 13.5.3 Covered Services ............................................................................................... 193 13.5.4 Non-Covered Services ....................................................................................... 194 13.5.5 Provisions of Mental Health and Substance Abuse Treatment Services to Residents of Nursing Facilities.......................................................................... 195 13.5.6 Billing Codes ..................................................................................................... 195 13.6 13.6.1 Ch. 13 Index Applied Behavioral Analysis Treatment ........................................................... 197 Covered Services ............................................................................................... 197 170 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ 13.6.2 Applied Behavior Analysis Providers ............................................................... 199 13.7 Limitations for Behavioral Health Services ...................................................... 200 13.8 Cap Limits ......................................................................................................... 200 13.9 Documentation Requirements for All Behavioral Health Providers ................. 200 13.9.1 Provider Agreement .......................................................................................... 201 13.9.2 Documentation of Services ............................................................................... 201 13.9.3 Client Records ................................................................................................... 202 13.9.3.1 Requirements ................................................................................................. 202 13.9.3.2 Clinical Records Content Requirement ......................................................... 204 13.9.4 Treatment Plans ................................................................................................. 205 13.9.5 Billing Requirements ......................................................................................... 205 13.9.6 Time and Frequency .......................................................................................... 206 13.9.7 Pre-Admission Screening and Resident Review (PASRR) Assessments ......... 206 13.9.7.1 Ch. 13 Index Billing Requirements ..................................................................................... 206 171 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ 13.1 Behavioral Health Services Outpatient Behavioral Health Services are a group of services designed to provide medically necessary mental health or substance abuse treatment services to Medicaid clients in order to restore these individuals to their highest possible functioning level. Services may be provided by any willing, qualified provider. Services are provided on an outpatient basis and not during an inpatient hospital stay. Wyoming Medicaid covers medically necessary therapy services, including mental health and substance abuse (behavioral health) treatment services via the federal authority guidelines granted by the Centers for Medicare and Medicaid Services (CMS) and specified in the Code of Federal Regulation's (CFR) rehabilitative services option section. All Medicaid clients who meet the service eligibility requirements and have a need for particular rehabilitative option services are entitled to receive them. "Medical necessity" or "Medically necessary" means a determination that a health service is required to diagnose, treat, cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected to relieve pain or to improve and preserve health and be essential to life. The service must be: o Consistent with the diagnosis and treatment of the client's condition; o In accordance with the standards of good medical practice among the provider's peer group; o Required to meet the medical needs of the client and undertaken for reasons other than the convenience of the client and the provider; and, o Performed in the most cost effective and appropriate setting required by the client's condition. Restorative (Rehabilitative) Services – Services that help patients keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the client was sick, hurt or suddenly disabled. Maintenance (Habilitative) Services – Services that help patients keep, learn, or improve skills and functioning for daily living. Examples would include therapy for a child who isn’t walking or talking at the expected age. 13.2 Requirements for Community Mental Health Centers (CMHC) and Substance Abuse Centers Community Mental Health Centers (CMHC) and Substance Abuse Treatment Centers (SATC) shall meet the following criteria to be enrolled as a Medicaid provider. Prior to enrollment as a Medicaid provider, a mental health center shall have received certification from the Behavioral Health Division as evidence of compliance. The center shall also have resolved any compliance deficiencies within time lines specified by the certifying Division. To become a provider of Medicaid mental health services, an agency shall apply for certification as a mental health and/or substance use Medicaid provider by submitting Ch. 13 Index 172 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ the Medicaid provider certification application form and its required attachments to the Behavioral Health Division. To become a provider of Medicaid mental health services, an agency shall be under contract with the Behavioral Health Division; and be certified by the Behavioral Health Division for the services for which the agency provides under the contract. 13.2.1 Provider’s Role Each Medicaid provider shall be certified under state law to perform the specific services. Certify that each covered service provided is medically necessary, rehabilitative and is in accordance with accepted norms of mental health and substance use practice. Providers are required to maintain records of the nature and scope of the care furnished to Wyoming Medicaid clients. 13.2.2 Responsibilities of Mental Health/Substance Abuse Providers Each client shall be referred by a licensed practitioner who attests to medical necessity as indicated by the practitioner’s signature, date on the clinical assessment and on the initial and subsequent treatment plans which prescribe rehabilitative, targeted case management or ESPDT mental health services. Licensed practitioners who are eligible to refer and to sign for medical necessity are persons who have current license from the State of Wyoming to practice as a: o Licensed Professional Counselor o Licensed Addictions Therapist o Licensed Psychologist o Licensed Clinical Social Worker o Licensed Marriage and Family Therapist o Licensed Physician o Licensed Psychiatric Nurse (Masters) o Licensed Advanced Practitioner of Nursing (Specialty area of psychiatric/mental health nursing) For a licensed practitioner to be authorized to refer and to sign for medical necessity, the agreement between the licensed practitioner and the provider by which the practitioner’s responsibilities under the Medicaid Mental Health Rehabilitative Option, Targeted Case Management Option and EPSDT mental health services are specified. Any licensed practitioner under contract with, or employed by, a provider shall be required to submit Medicaid claims through the provider and to indicate the provider as payee. All individuals providing services must have their own provider number. Prior to the provider’s billing Medicaid for Mental Health Rehabilitative Option, Targeted Case Management Option and EPSDT mental health Ch. 13 Index 173 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ services a licensed practitioner shall sign, date and add their credentials to the client’s clinical assessment, written treatment plan and clinical notes. Licensed practitioners who sign for services that are not medically necessary and rehabilitative in nature are subject to formal sanctions through Wyoming Medicaid and/or referral to the relevant licensing board. 13.2.3 Qualification for Participating Provider and Staff TO BE ELIGIBLE TO PROVIDE MEDICAID MENTAL HEALTH CLINICAL SERVICES STAFF SHALL: Be employed or under contract with the Behavioral Health Division as a certified mental health center and enrolled Medicaid provider, and Be licensed, provisionally licensed, or certified by the State of Wyoming, or Be a registered nurse (R.N.), licensed in the State of Wyoming, who has at least two years of supervised experience and training to provide mental health services after the awarding of the R.N. Be a clinical professional, clinical staff, or qualified as a case manager per the requirements of the service provided as pursuant to Wyoming Medicaid Rules, Chapter 13- Mental Health Services. TO BE ELIGIBLE TO PROVIDE MEDICAID TREATMENT SERVICES, STAFF SHALL: SUBSTANCE USE Be employed or under contract with the Behavioral Health Division as a certified substance use treatment center and enrolled Medicaid provider, and Be a licensed, provisionally licensed or certified by the State of Wyoming, or Be a registered nurse (R.N.), licensed in the State of Wyoming, who has at least two years of supervised experience and training to provide mental health services after the awarding of the R.N. Be a clinical professional, clinical staff, or qualified as a case manager per the requirements of the service provided as pursuant to Wyoming Medicaid Rules, Chapter 13- Mental Health Services. TO BE ELIGIBLE TO PROVIDE MEDICAID REHABILITATIVE SERVICES, STAFF SHALL: INDIVIDUAL Be employed or under contract with the Behavioral Health Division certified Medicaid provider. Be eighteen years of age or older. Complete a basic training program, including non-violent behavioral management, and Be supervised and meet the qualifications of a certified mental health worker as pursuant to Wyoming Mental Health Professions Board, Chapter 1General Provisions. Under the direct supervision of the primary therapist for that client. Ch. 13 Index 174 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ TO BE ELIGIBLE TO PROVIDE PEER SPECIALIST SERVICES, STAFF SHALL: Be employed or under contract with the Behavioral Health Division certified Medicaid provider. Self-identify as a person in recovery from mental illness and/or substance use disorder. Be eighteen years of age or older. Be credentialed by the Behavioral Health Division as a peer specialist, and Be supervised for the position by a person licensed by the Wyoming Mental Health Professions Licensing Board or by a person with at least five (5) contiguous years of experience as a Credentialed Peer Specialist. Supervisors of Peer Specialists must complete at least 16 hours of direct contact training on the supervision of Peer Specialists. Be under the direct supervision of the primary therapist for that client. TO BE ELIGIBLE TO PROVIDE CASE MANAGEMENT SERVICES, STAFF SHALL: Be employed or under contract with the Behavioral Health Division certified mental health or substance use treatment center and enrolled as a Medicaid provider, and Be a mental health or substance use treatment professional, a mental health or substance use treatment counselor, a mental health or substance use treatment assistant as pursuant to Wyoming Medicaid Rules, Chapter 13- Mental Health Services, or Be a registered nurse (R.N.), licensed in the State of Wyoming, who has at least two years of clinical experience after the awarding of the R.N. Knowledgeable of the community and have the ability to work with other agencies All documentation, including required signatures, must be completed at the time the service is completed. 13.3 Covered Services for Community Mental Health and Substance Abuse Treatment Centers The following rehabilitative services are allowable for outpatient community mental health and substance abuse treatment services: 13.3.1 Rehabilitative Option Services Adult Psychosocial Rehabilitation: Skills addressed may include: o Emotional skills, such as coping with stress, managing anxiety, dealing constructively with anger and other strong emotions, coping with depression, managing symptoms, dealing with frustration and disappointment and similar skills. Ch. 13 Index 175 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Ch. 13 Index o Behavioral skills, such as managing overt expression of symptoms like delusions and hallucinations, appropriate social and interpersonal interactions, proper use of medications, extinguishing aggressive/assaultive behavior. o Daily living and self-care, such as personal care and hygiene, money management, home care, daily structure, use of free time, shopping, food selection and preparation and similar skills. o Cognitive skills, such as problem solving, concentration and attention, planning and setting, understanding illness and symptoms, decision making, reframing, and similar skills. o Community integration skills, which focus on the maintenance or development of socially valued, age appropriate activities. o And similar treatment to implement each enrolled client’s treatment plan. o Excludes the following services, academic education, recreational activities, meals and snacks and vocational services and training. Agency/Based Individual/Family Therapy Peer Specialist Services Children’s Psychosocial Rehabilitation: This service is designed to address the emotional and behavioral symptoms of youth diagnosed with childhood disorder, including ADHD, Oppositional Defiant Disorder, Depression, Disruptive Behavior Disorder and other related children’s disorder. Within this service there are group and individual modalities and a primary focus on behaviors that enhance a youth’s functioning in the home, school, and community. Youth will acquire skills such as conflict resolution, anger management, positive peer interaction and positive self-esteem. Treatment interventions include group therapy, activity based therapy, psychoeducational instruction, behavior modification, skill development, and similar treatment to implement each enrolled client’s treatment plan. The day treatment program may include a parent group designed to teach parents the intervention strategies used in the program. Clinical Assessment Community-Based Individual/Family Therapy Comprehensive Medication Services Group Therapy Individual Rehabilitative Services Intensive Individual Rehabilitative Services Substance Use Intensive Outpatient Treatment Services: Direct contact with two or more enrolled clients (and collaterals as necessary) for the purpose of providing a preplanned and structured program of group treatment which may include education about role functioning, illness and medications; group therapy and problem solving, and similar treatment to implement each enrolled client’s treatment plan. Psychiatrist Services: These mental health and substance abuse treatment services are covered by Medicaid when it is determined to be medically necessary and rehabilitative in nature. 176 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ 13.3.2 Targeted Case Management Targeted Case Management for adults with serious mental illness age twenty-one (21) and over is an individual, non-clinical service which will be used to assist individuals under the plan in gaining access to needed medical, social, educational, and other services. The purpose of targeted case management is to foster a client’s rehabilitation from a diagnosed mental disorder or substance use disorder by organizing needed services and supports into an integrated system of care until the client is able to assume this responsibility. Targeted case management activities include the following: Linkage: Working with clients and/or service providers to secure access to needed services. Activities include communication with agencies to arrange for appointments or services following the initial referral process, and preparing clients for these appointments. Contact with hospitalized clients, hospital/institution staff, and/or collaterals in order to facilitate the client’s reintegration in to the community. Monitoring/Follow-Up: Contacting the client or others to ensure that a client is following a prescribed service plan and monitoring the progress and impact of that plan. Referral: Arranging initial appointments for clients with service providers or informing clients of services available, addresses and telephone numbers of agencies providing services. Advocacy: Advocacy on behalf of a specific client for the purpose of accessing needed services. Activities may include making and receiving telephone calls, and the completion of forms, applications and reports which assist the client in accessing needed services. Crisis Intervention: Crisis intervention and stabilization are provided in situation requiring immediate attention/resolution for a specific client. The case manager may provide the initial intervention in a crisis situation and would assist the client in gaining access to other needed crisis services. The client’s primary therapist (employed or contracted by the community mental health or substance use treatment center) will perform an assessment and determine the case management services required. 13.3.3 EPSDT Mental Health Services or Ongoing Case Management Ongoing Case Management: Ongoing Case Management for persons under age twenty one (21) is an individual, non-clinical service which will be used to assist individuals under the plan in gaining access to needed medical, social, educational, and other services. The purpose of Ongoing case management is to foster a client’s rehabilitation from a diagnosed mental disorder or substance use disorder by organizing needed services and supports into an integrated system of care until the client or family is able to assume this responsibility. Ch. 13 Index 177 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Ongoing case management activities include the following: Linkage: Working with clients and/or service providers to secure access to needed services. Activities include communication with agencies to arrange for appointments or services following the initial referral process, and preparing clients for these appointments. Contact with hospitalized clients, hospital/institution staff, and/or collaterals in order to facilitate the client’s reintegration into the community. Monitoring/Follow-up: Contacting the client or others to ensure that a client is following a prescribed service plan and monitoring the progress and impact of that plan. Referral: Arranging appointments for clients with service providers or informing clients of services available, addresses and telephone numbers of agencies’ providing services. Advocacy: Advocacy on behalf of a specific client for the purpose of accessing needed services. Activities may include making and receiving telephone calls, and the completion of forms, applications and reports which assist the client in accessing needed services. Crisis Intervention: Crisis Intervention and stabilization are provided in situations requiring immediate attention/resolution for a specific client. The case manager may provide the initial intervention in a crisis situation and would assist the client in gaining access to other needed crisis services. The client’s primary therapist will perform an assessment and authorize the case management services required. 13.3.4 Limitations to Mental Health/Substance Abuse Services Medicaid Mental Health Rehabilitative Targeted Case Management Option and EPSDT mental health services are limited to those eligible persons who have a primary diagnosis of a mental/substance use disorder in the most current edition of the Diagnostic and Statistical Manual Disorders (DSM) or ICD equivalent. Specifically excluded from eligibility for Rehabilitative Option, Targeted Case Management Option and EPSDT mental health services are the following diagnosis resulting from clinical assessment: o Sole DSM diagnosis of mental retardation o Sole DSM diagnosis of any Z code and services provided for a Z code diagnosis (exception for young children) o Sole DSM diagnosis of other unknown and unspecified cause of morbidity and mortality o Sole DSM diagnosis of specific learning disorders Habilitative services are not covered for clients twenty-one (21) years of age or older. 13.3.5 Quality Assurance The quality assurance program of a provider shall, at minimum, meet these criteria: Ch. 13 Index 178 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Utilization and quality review criteria Agency standards for completeness review and criteria for clinical records Definition of critical incidents which require professional review and review procedures 13.4 Community Mental Health & Substance Abuse Treatment Centers Billing Procedures The following matrix indicates the HCPCS Level II code, the Medicaid defined unit (for codes without a specific time span in the HCPCS Level II coding book) and acceptable modifiers (when applicable). 13.4.1 Psychiatric Services Community Mental Health Centers will be reimbursed for psychiatric services at the same fee currently established for psychiatrists in private practices. Community Mental Health Centers must use current CPT codes when billing for these services. Refer to Psychiatric and Mental Health Services (13.6, Eligible Providers). Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) 1 Unit Equals G9012 Per 15 minutes T1017 Per 15 minutes Ch. 13 Index Description Ongoing Case Management(<21) Adult Case Management – Targeted Case Management (>21) 179 Taxonomies Allowed 101YA0400X, 101YP2500X, 101Y00000X, 103G00000X, 103TC0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, 1041C0700X, Taxonomies beginning with 20 (Physicians) 101Y00000X, 101YP2500X, 101YA0400X, 103TC0700X, 103G00000X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 251B00000X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) 1 Unit Equals H0031 Per 15 minutes H0034 Per 15 minutes H2014 Description Taxonomies Allowed 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, Clinical Assessment – 106H00000X, 163W00000X, Mental Health Assessment 2084P0800X, 364SP0808X, by non-physician Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X Comprehensive Medication 101YP2500X, 163W00000X, Service – Medication 164W00000X, 364SP0808X, Training and Support 261QM0801X Per 15 minutes Individual Rehabilitative Service – Skills Training and Development 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 164W00000X, 171M00000X, 172V00000X, 261QM0801X H2014 HH Per 15 minutes Certified Peer Specialists 172V00000X, 261QM0801X H2014 HH + HQ Per 15 minutes Certified Peer Specialists 172V00000X, 261QM0801X H2015 HH Per 15 minutes Certified Peer Specialists 172V00000X, 261QR0405X H2015 HH, HQ Per 15 minutes Certified Peer Specialist – Group 172V00000X, 261QR0405X Psychosocial Rehabilitation Services 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, 261QM0801X Children’s Psychosocial Rehabilitation Services 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, 261QM0801X H2017 H2017 Ch. 13 Index Per 15 minutes EP Per 15 minutes 180 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) H2019 H2019 1 Unit Equals Per 15 minutes HQ Per 15 minutes H2021 Per 15 minutes H2010 Per 15 minutes H0047 Per 15 minutes T1012 Per 15 minutes H0005 Per 15 minutes Ch. 13 Index Description Taxonomies Allowed Agency Based Individual/Family Therapy 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 2084P0800X, Taxonomies beginning with 20 (Physicians), 261QM0801X Group Therapy – Group Counseling by Clinician 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 2084P0800X, Taxonomies beginning with 20 (Physicians), 261QM0801X 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, Community-Based 106H00000X, 163W00000X, Individual/Family Therapy 2084P0800X, Taxonomies beginning with 20 (Physicians), 261QM0801X Comprehensive Medication 101YP2500X, 163W00000X, Therapy 164W00000X, 171M00000X, 172V00000X, 261QR0405X Alcohol/Drug Services – 101Y00000X, 101YA0400X, NOS, Community Based 101YP2500X, 103G00000X, Individual/Family Therapy 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 2084P0800X, 261QR0405X Alcohol/Drug Services – 101Y00000X, 101YA0400X, Skill Development 101YP2500X, 1041C0700X, (Psychosocial Rehab 106H00000X, 163W0000X, Service) 171M00000X, 261QR0405X Alcohol/Drug Services – 101Y00000X, 101YA0400X, Group Counseling by 101YP2500X, 103G00000X, Clinician 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 261QR0405X 181 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) 1 Unit Equals Description Taxonomies Allowed 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 163W00000X, 164W00000X, 171M00000X, 172V00000X, 261QR0405X 101Y00000X, 101YA0400X, 101YP2500X, 103TC0700X, 103G00000X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X H2015 Per 15 minutes Comprehensive Community Support Services – Individual Rehab Services H0006 Per 15 minutes Alcohol/Drug Services – Case Management H0006 EP Per 15 minutes Substance Abuse Case Management (Youth) H0006 HQ Per 15 minutes Alcohol/Drug Services – Case Management – Group T2011 Ch. 13 Index PASRR Level II Psychiatric Evaluation/Determination of Appropriate Placement 182 101Y00000X, 101YA0400X, 101YP2500X, 103TC0700X, 103G00000X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YA0400X, 101YP2500X, 103TC0700X, 103G00000X, 1041C0700X, 106H00000X, 163W00000X, 171M00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians),261QM0801X Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) 1 Unit Equals 90785 CPT Defined 90791 CPT Defined 90792 CPT Defined 90832 CPT Defined 90833 CPT Defined 90834 CPT Defined Ch. 13 Index Description Taxonomies Allowed 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, Interactive complexity (list 103TC0700X, 1041C0700X, separately in addition to the 106H00000X, 364SP0808X, code for primary procedure) Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YP2500X, 101YA0400X, 103G00000X, 103TC0700X, 1041C0700X, Psychiatric Diagnostic 106H00000X, 364SP0808X, Evaluation Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 103G00000X, 103TC0700X, Psychiatric diagnostic 364SP0808X, Taxonomies evaluation with medical beginning with 20 services (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, Psychotherapy, 30 minutes 103TC0700X, 1041C0700X, with patient and/or family 106H00000X, 364SP0808X, member Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X Psychotherapy, 30 minutes with patient and/or family 103TC0700X, 103G00000X, member when performed 364SP0808X, Taxonomies with an evaluation and beginning with 20 management service (list (Physicians). 261QM0801X, separately in addition to the 261QR0405X code for primary procedure) 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, Psychotherapy, 45 minutes 103TC0700X, 1041C0700X, with patient and/or family 106H00000X, 364SP0808X, member Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 183 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Centers HCPCS Level II Code 90836 90837 90838 90845 Modifier(s) 1 Unit Equals Description Taxonomies Allowed CPT Defined Psychotherapy, 45-minutes with patient and/or family member when performed with an evaluation and management service (list separately in addition to the code for primary procedure) 103TC0700X, 103G00000X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X CPT Defined Psychotherapy, 60 minutes with patient and/or family member 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X CPT Defines Psychotherapy, 60 minutes with patient and/or family member when performed with an evaluation and management services (list separately in addition to the code for primary procedure) 103G00000X, 103TC0700X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X CPT Defined Psychoanalysis 90846 CPT Defined Family Medical Psychotherapy (without the patient present) 90847 CPT Defined Family Psychotherapy Ch. 13 Index 184 101Y00000X, 101YA0400X 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101YP2500X, 103G00000X, 103TC0700X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health & Substance Abuse Treatment Centers Modifier(s) Description EP Services provided as part of EPSDT HH Peer Specialist HQ Group setting Community Mental Health & Substance Abuse Centers HCPCS Level II Code Modifier(s) 1 Unit Equals Description 90849 CPT Defined Multiple-Family Group Psychotherapy 90853 CPT Defined Group Medical Psychotherapy 96101-96103, 96120 CPT Defined Central Nervous System Assessments/Psychological Testing CPT Defined Central Nervous System Assessments/Psychological Testing 96105, 9611096111, 96116, 96118-96119, 96125 Ch. 13 Index 185 Taxonomies Allowed 101Y00000X, 101YA0400X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 101Y00000X, 101YA0400X 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X, 261QR0405X 103G00000X, 103TC0700X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians), 261QM0801X 103G00000X, 103TC0700X, 2084P0800X, 364SP0808X, Taxonomies beginning with 20 (Physicians) Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Taxonomy 101Y00000X 101YA0400X 101YP2500X 103G00000X 103TC0700X 1041C0700X Ch. 13 Index Community Mental Health Centers Provider Types Allowed Codes G9012, H0031, H2014, H2014 + HK, H2017, H2017 + EP, H2019, Provisional Professional Counselor (PPC), H2019 + HQ, H2021, T1017, Certified Mental Health Worker T1017 + EP, T2011, 90785, 90791, 90832, 90834, 90837, 90845, 90847, 90849, 90853 G9012, H0031, H2014, H2014 + Licensed Addictions Therapist (LAT), HK, H2017, H2017 + EP, H2019, Provisionally Licensed Addictions Therapist H2019 + HQ, H2021, T1017, (PLAT), Certified Addictions Practitioner T1017 + EP, T2011, 90785, (CAP) 90791, 90832, 90834, 90837, 90845, 90847, 90849, 90853 G9012, H0034, H2014, H2014 + HK, H2017, H2017 + EP, H2019, H2019 + HQ, H2021, T1017, Licensed Professional Counselor (LPC) T1017 + EP, 90791, 90785, 90832, 90834, 90837, 90846, 90847, 90849, 90853, H0031, G9012, H0031, H2014, H2014 + HK, H2017, H2019, H2021, T1017, T1017 + EP, T2011, 90785, 90791, 90792, 90832Neuropsychologist 90834, 90836-90839, 9084590847, 90849, 90853, 9610196103, 96105, 96110-96111, 96116, 96118-96120, 96125 G9012, H0031, H2014, H2014 + HK, H2017, H2019, H2021, T1017, T1017 + EP, T2011, 90785, 90791, 90792, 90832Clinical Psychologist 90834, 90836-90839, 9084590847, 90849, 90853, 9610196103, 96105, 96110-96111, 96116, 96118-96120, 96125 G9012, H0031, H2014, H2014 +HK, H2017, H2017 + EP, Licensed Clinical Social Worker (LCSW), H2019, H2019 + HQ, H2021, Certified Social Worker (CSW) T1017, T1017 + EP, T2011, 90785, 90791, 90832, 90834, 90837, 90845 186 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Community Mental Health Centers Provider Types Allowed Codes G9012, H0031, H2014, H2014 + HK, H2017, H2017 + EP, H2019, Marriage and Family Therapist (MFT), H2019 + HQ, H2021, T1017, 106H00000X Provisionally Licensed Marriage and Family T1017 + EP, T2011, 90785, Therapist (PMFT) 90791, 90832, 90834, 90837, 90845, 90849, 90853 G9012, H0031, H0034, H2014, H2014 + HK, H2017, H2017+EP, 163W00000X RN H2019, H2021, T1017, T1017 + EP G9012, H0034, 164W00000X LPN H2014,H2014+HK G9012, H2014, H2014 + HK, 171M00000X Case Manager H2017, H2017 + EP, T1017, T1017 + EP Community Health Worker – Individual Rehabilitative Services Worker (IRS), H2014, H2014 + HK, H2014 + 172V00000X Certified Peer Specialist, Certified HH, H2014 + HH+ HQ Addictions Practitioner Assistant (CAPA) G9012, H0031, H2019, H2019 + HQ, H2021, T1017, T1017 + EP, 90785, 90791, 90792, 90832Taxonomies 90834, 90836-90839, 90845 beginning Physicians 90846, 90847, 90849, 90853, with 20 96101-96103, 96105, 9611096111, 96116, 96118-96120, 96125 G9012, H0031, H2017, H2017 + EP, H2019, H2019 + HQ, H2021, T1017, T1017 + EP, T2011, 90785, 90791, 90792, 908322084P0800X Psychiatry and Neurology, Psychiatry 90834, 90836-90839, 9084590847, 90849, 90853, 9610196103, 96105, 96110-96111, 96116, 96118-96120, 96125 G9012, H0031, H0034, H2017, H2017 + EP, H2021, T1017, T1017 + EP, T2011, 90785, Nurse Practitioner, Advanced Practice, 90791, 90792, 90832-90834, 364SP0808X Psychiatric/Mental Health 90836-90839, 90845-90847, 90849, 90853, 96101-96103, 96105, 96110-96111, 96116, 96118-96120, 96125 Taxonomy Ch. 13 Index 187 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Substance Abuse Treatment Centers Taxonomy Provider Types 101Y00000X Provisional Professional Counselor (PPC), Certified Mental Health Worker G9012, H0031, H0005, H0006, H0006 + EP, H0006 + HQ, H0047, H2015, H2015 + HK, T1017, T1012, 90785, 90791, 90832, 90834, 90837, 90847, 90849, 90853 101YA0400X Licensed Addictions Therapist (LAT), Provisionally Licensed Addictions Therapist (PLAT), Certified Addictions Practitioner (CAP) G9012, H0031, H0005, H0006, H0006 + EP, H0006 + HQ, H0047, H2015, H2015 + HK, T1017, T1012, 90785, 90791, 90832, 90834, 90837, 90847, 90849, 90853 Licensed Professional Counselor (LPC) G9012, H0031, H0005, H0006, H0006 + EP, H0006 + HQ, H0047, H2015, H2015 + HK, T1017, T1012, 90785, 90791, 90832, 90834, 90837, 90846, 90847, 90849, 90853 Neuropsychologist G9012, H0005, H0006, H0006 + EP, H0006 + HQ, H2015, H2015 + HK, T1017, 90785, 90791, 90792, 90832-90834, 90836-90838, 90845- 90847, 90849, 90853, 96101-96103, 96105, 96110-96111, 96116, 96118-96120, 96125 103TC0700X Clinical Psychologist G9012, H0005, H0006, H0006 + EP, H0006 + HQ, H2015, H2015 + HK, T1017, 90785, 90791, 90792, 90832-90834, 90836-90838, 90845- 90847, 90849, 90853, 96101-96103, 96105, 96110-96111, 96116, 96118-96120, 96125 1041C0700X Licensed Clinical Social Worker (LCSW), Certified Social Worker (CSW) G9012, H0031, H0005, H0006, H0006 + EP, H0006 + HQ, H0047, H2015, H2015 + HK, T1017, T1012, 90785, 90791, 90832, 90834, 90837, 90847, 90849, 90853 106H00000X Marriage and Family Therapist (MFT), Provisionally Licensed Marriage and Family Therapist (PMFT) G9012, H0031, H0005, H0006, H0006 + EP, H0006 + HQ, H0047, H2015, H2015 + HK, T1017, T1012, 90784, 90791, 90832, 90834, 90837, 90847, 90849, 90853 163W00000X RN G9012, H0005, H0006, H0006 + EP, H0006 + HQ, H2010, H2015, H2015 + HK, H0047, T1017, T1012 164W00000X LPN H2010, H2015, H2015 + HK 171M00000X Case Manager 101YP2500X 103G00000X Ch. 13 Index Allowed Codes G9012, H0006, H0006 + EP, H0006 + HQ, H2015, H2015 + HK + T1012 188 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Substance Abuse Treatment Centers Taxonomy Provider Types 172V00000X Community Health Worker – Individual Rehabilitative Services Worker (IRS), Certified Peer Specialist, Certified Addictions Practitioner Assistant (CAPA) H2010, H2015, H2015 + HK, H2015 + HH, H2015 + HH + HQ Psychiatry and Neurology, Psychiatry G9012, H0006, H0006 + EP, H0006 + HQ, T1017, 90785, 90791, 90792, 90832-90834, 90836-90838, 90846, 90849, 90853, 9610196103, 96105, 96110-96111, 96116, 9611896120, 96125 Physicians G9012, H0006, 90785, 90791, 90792, 9083290834, 90836-90838, 90845-90847, 90849, 90853, 96101-96103, 96105, 96110-96111, 96116-96120, 96125 Nurse Practitioner, Advanced Practice, Psychiatric/Mental Health G9012, H0006, H0006 + EP, H0006 + HQ, 90785, 90791, 90792, 90832-90834, 9083690838, 90845-90847, 90849, 90853, 9610196125 2084P0800X Taxonomies beginning with 20 364SP0808X 13.5 Allowed Codes Eligible Providers Individual and/or Group Providers Shall be enrolled as an individual or in one (1) of the following groups: Licensed Professional Counselor (LPC) 101YP2500X Psychiatry CMHC SATC Developmental Center Psychologist Neuropsychologist Physician Shall be enrolled as an individual or in one (1) of the following groups: Licensed Addictions Therapist (LAT) 101YA0400X Neuropsychologist 103G00000X Clinical Psychologist 103TC0700X Ch. 13 Index Psychiatry Psychologist CMHC Neuropsychologist SATC Physician Developmental Center Shall be enrolled as an individual or in one (1) of the following groups: CMHC SATC Physician Shall be enrolled as an individual or in one (1) of the following groups: CMHC SATC Physician LAT 189 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Individual and/or Group Providers Licensed Clinical Social Worker (LCSW) 1041C0700X Licensed Marriage and Family Therapist (LMFT) 106H00000X Shall be enrolled as an individual or in one (1) of the following groups: Psychiatry Psychologist CMHC Neuropsychologist SATC Physician Developmental Center Shall be enrolled as an individual or in one (1) of the following groups: Psychiatry Psychologist CMHC Neuropsychologist SATC Physician Developmental Center Only Enrolled Under Supervision Certified Mental Health Worker (CMHW) 101Y00000X Certified Addictions Practitioner (CAP) 101YA0400X Certified Social Worker (CSW) 1041C0700X Community Health Worker – Individual Rehabilitative Services Worker (IRS) 172V00000X Certified Addictions Practitioner Assistant (CAPA) 172V00000X Ch. 13 Index Shall be under the supervision of a Qualified Clinical Supervisor and employer; AND Shall be enrolled in one (1) of the following groups: Psychologist Neuropsychologist CMHC SATC Shall be under the supervision of a Licensed Professional and Employer; AND Shall be enrolled in one (1) of the following groups: Psychologist CMHC Neuropsychologist SATC Shall be under the supervision of a Qualified Clinical Supervisor and employer; AND Shall be enrolled in one (1) of the following groups: Psychologist CMHC Neuropsychologist SATC Shall be under the supervision of a Licensed Professional and Employer; AND Shall be enrolled in one (1) of the following groups: CMHC SATC Shall be under the supervision of a Licensed Professional and Employer; AND Shall be enrolled in one (1) of the following groups: CMHC 190 SATC Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Providers MUST be enrolled in a group Provisional Professional Counselor (PPC) 101Y00000X Provisional Licensed Addictions Therapist (PLAT) 101YA0400X Master of Social Worker (MSW) with Provisional License (PCSW) 1041C0700X Provisional Marriage and Family Therapist (PMFT) 106H00000X Registered Nurse (RN) 163W00000X Shall be enrolled in one (1) of the following groups: CMHC SATC Psychiatry Psychologist Neuropsychologist Physician LPC LCSW LAT LMFT Developmental Center Shall be enrolled in one (1) of the following groups: CMHC SATC Psychiatry Psychologist Neuropsychologist Physician LPC LCSW LAT LMFT Developmental Center Shall be enrolled in one (1) of the following groups: CMHC SATC Psychiatry Psychologist Neuropsychologist Physician LPC LCSW LAT LMFT Developmental Center Shall be enrolled in one (1) of the following groups: CMHC SATC Psychiatry Psychologist Neuropsychologist Physician LPC LCSW LAT LMFT Developmental Center Shall only be enrolled in one (1) of the following groups: CMHC SATC Licensed Practical Nurse (LPN) 164W00000X Shall only be enrolled in one (1) of the following groups: Case Manager 172V00000X Shall only be enrolled in one (1) of the following groups: Certified Peer Specialist 172V00000X Shall only be enrolled in one (1) of the following groups: 13.5.1 CMHC CMHC SATC SATC SATC Psychiatric Services Ch. 13 Index CMHC Psychiatric Services – Medicaid covers medically necessary psychiatric and mental health services when provided by the following practitioners: o Psychiatrists or Physicians; or 191 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ o APN/PMHNP (Advance Practice Nurse/Psychiatric Mental Health Nurse Practitioner. APN/PMHNP Services – Medicaid covers medically necessary psychiatric services when provided by an APN/PMHNP. o The APN/PMHNP must have completed a nursing education program and national certification that prepares the nurse as a specialist in Psychiatric/Mental Health and is recognized by the State Board of Nursing in that specialty area of advance practice. 13.5.1.1 Psychologists Medicaid covers medically necessary mental health and substance abuse disorder treatment and recovery services provided by psychologists and/or the following mental health professionals, when they are directly supervised by a licensed psychologist: Persons who are provisionally licensed by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act. Psychological residents or interns as defined by the Wyoming State Board of Psychology Rules and Regulations. Certified social worker or certified mental health worker, certified by the Mental Health Professions Licensing Board pursuant to the Mental Health Professions Practice Act. 13.5.1.2 Licensed Mental Health Professionals Medicaid covers medically necessary mental health and substance abuse disorder treatment and recovery services provided by Licensed Mental Health Professionals (LMHPs). The LMHPs include Licensed Professional Counselors, Licensed Certified Social Workers, Licensed Addictions Therapists and Licensed Marriage and Family Therapists. LMHPs may enroll independently and must bill using their own National Provider Identifier (NPI) or may enroll as members of a Mental Health group and are required to bill with the group’s National Provider Identifier (NPI) as the pay to provider, and the individual treating providers NPI as the rendering provider at the line level. 13.5.1.3 Provisional Licensed Mental Health Professionals Medicaid covers medically necessary mental health and substance abuse disorder treatment and recovery services provided by Provisional Licensed Mental Health Professionals which includes Provisional Professional Counselors, Provisional Licensed Addictions Therapists, Master of Social Work with Provisional License, and Provisional Marriage and Family Therapists. The Provisional Licensed Mental Health Professionals may enroll with a CMHC or SATC, physician, psychologist, or under the supervision of a LMHP. They must bill using their own National Provider Identifier (NPI) or may enroll as members of a Mental Health group and are required Ch. 13 Index 192 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ to bill with the group’s National Provider Identifier (NPI) as the pay to provider, and their individual treating provider NPI as the rendering provider at the line level. 13.5.1.4 Supervision Supervision is defined as the ready availability of the psychiatrist/physician, psychologist or LMHPs for consultation and direction of the activities of the mental health professionals in the office. Contact with the supervising practitioner (physician /psychiatrist, psychologist, or LMHPs) by telecommunication is sufficient to show ready availability, if such contact provides quality care. The supervising practitioner maintains final responsibility for the care of the client and the performance of the mental health professional in their office. 13.5.2 Behavioral Health Providers Eligible for Medicare Enrollment Taxonomy codes listed in the table below can enroll in Medicare and are required to bill Medicare prior to billing Medicaid for services rendered to clients that have Medicare as primary insurance. If a group is enrolled with one of the taxonomy codes listed in the table, the group MUST bill Medicare prior to billing Medicaid. For these groups, the rendering provider treating a client with Medicare as primary MUST also be enrolled in Medicare. If the rendering provider cannot enroll in Medicare due to taxonomy code, they will not be able to treat clients that have Medicare as primary. Taxonomy Codes Eligible for Medicare Enrollment Taxonomy Description 2084P0800X Psychiatrist 103TC0700X Licensed Psychologist 1041C0700X Licensed Clinical Social Worker (LCSW) For behavioral health providers that cannot enroll in Medicare due to taxonomy code, and do not belong to a group with the taxonomy codes listed in the table, these providers can bill Medicaid directly for services rendered to clients with Medicare as primary. 13.5.3 Covered Services Ch. 13 Index Clinical Assessment - Contact with the recipient (and collaterals as necessary) for the purposes of completing an evaluation of the recipient’s mental health and/or substance abuse disorder(s) to determine treatment needs 193 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ 13.5.4 and establish a treatment plan. This service may include psychological testing if indicated. Agency or Office-based individual/family therapy services - Direct contact, within the provider’s office or agency, with the recipient and/or collaterals for the purpose of developing and implementing the treatment plan for an individual or family. This service is targeted at reducing or eliminating specific symptoms or behaviors which are related to a recipient’s mental health or substance abuse disorder as specified in the treatment plan. Community-based individual/family therapy services - Direct contact, outside of the provider’s office or agency, with the recipient and/or collaterals for the purpose of developing and implementing the treatment plan for an individual or family. This service is targeted at reducing or eliminating specific symptoms or behaviors which are related to a recipient’s mental health or substance abuse disorder as specified in the treatment plan. Group Therapy – Direct contact with two or more unrelated recipients and/or collaterals as necessary for the purpose of implementing each recipient’s treatment plan. This service is targeted at reducing or eliminating specific symptoms or behaviors related to a recipient’s mental health and/or substance abuse disorder(s) as identified in the treatment plan. Ongoing Case management – Direct contact with a client under age 21 to provide individual, non-clinical service which will be used to assist individuals under the plan in gaining access to needed medical, social, educational, and other services. Ongoing case management activities include linkage, monitoring of follow-up, referrals, advocacy and crisis intervention Non-Covered Services Hospital liaison services that include institutional discharge functions that are Medicaid reimbursable to the institution. Consultation to other persons and agencies about non-clients, public education, public relations activities, speaking engagements and education. Clinical services not provided through face-to-face contact with the client, other than collateral contacts necessary to develop/implement the prescribed plan of treatment. Residential room, board, and care. Substance use and mental health prevention services. Recreation and socialization services. Vocational services and training. Appointments not kept. Day care. Psychological testing done for the sole purpose of educational diagnosis or school placement. Remedial or other formal education. Travel time. Record keeping time. Ch. 13 Index 194 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Time spent writing test reports with the exception of three hours allowed for report writing by a licensed psychologist for the purpose of compiling a formal report of test findings and time spent completing reports, forms and correspondence covered under case management services. Time spent in consultation with other persons or organizations on behalf of a client unless: o The consultation is a face-to-face contact with collateral in order to implement the treatment plan of a client receiving Rehabilitative Option services. OR o The consultation is a face-to-face or telephone contact in order to implement the treatment plan of a client receiving EPSDT Mental Health Services. OR o The consultation is a face-to-face or telephone contact in order to implement the treatment plan of a client receiving Targeted Case Management Services. Groups such as Alcoholics Anonymous, Narcotics Anonymous, and other self-help groups, and Driving while under the influence (DUI) classes. Services provided by a school psychologist 13.5.5 Provisions of Mental Health and Substance Abuse Treatment Services to Residents of Nursing Facilities Eligibility for Medicaid mental health and substance use services provided to enrolled clients in the nursing facility is limited to the following services under the Rehabilitative Services Option: 13.5.6 Clinical Assessment Community-Based Individual/Family Therapy Group Therapy Psychiatric Services Billing Codes The following matrix indicates the Psychiatrist and APN/PMHNP CPT-4 codes. Please refer to the most current version of the CPT book. Interpretations or explanation of results of psychiatric services to family members or other responsible persons is included in the fee for psychotherapy. This list of codes is not all-inclusive; it does not contain all codes that Psychiatrists/Physicians & APN/PMHNP may bill. Psychiatrists/Physicians & APN/PMHNP Billing Codes CPT-4 Code 99201-99205 Ch. 13 Index Unit CPT Defined 195 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Psychiatrists/Physicians & APN/PMHNP Billing Codes CPT-4 Code 99211-99215 99217-99226 99231-99236 99238-99239 99241-99245 99251-99255 99304-99318 99324-99337 99341-99359 90785 90791-90792 90832-90834 90836-90838 90845-90847 90849 90853 G9012 Unit CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined CPT Defined 15 minutes The following matrix indicates the CPT-4 codes specific to psychological services. Please refer to the most current version of the CPT book. Psychologist Billing Codes Ch. 13 Index CPT-4 Code Unit 90785 CPT Defined 90791 CPT Defined 90832-90834 CPT Defined 90836-90838 CPT Defined 90845-90847 CPT Defined 90849 CPT Defined 90853 CPT Defined 96101-96125 CPT Defined 99366 CPT Defined G9012 15 minutes 196 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Licensed Mental Health Professionals have the following HCPCS Level II codes available to them for service provision: Billing Codes for Licensed Mental Health Professionals LMHP (LAT, LCSW, LMFT, LPC) and supervised Mental Health Professionals working under a physician/psychiatrist, LMHP or psychologist (CMHW, CSW and provisionally licensed mental health professionals-PAT, PCSW, PMFT, PPC) H0031 Clinical Assessment Office-Based Individual/Family H2019 Therapy H2019+HQ modifier Group Therapy Community-Based H2021 Individual/Family Therapy Ongoing Case Management for G9012 Clients <21 13.6 Applied Behavioral Analysis Treatment Applied Behavior Analysis (ABA) treatments are allowable to children between the ages of 0-20 years of age with a diagnosis of Autism Spectrum Disorder. Applied Behavior Analysis are individualized treatments based in behavioral sciences that focus on increasing positive behaviors and decreasing negative or interfering behaviors to improve a variety of well-defined skills. ABA is a highly structured program that includes incidental teaching, intentional environmental modifications, and reinforcement techniques to produce socially significant improvement in human behavior. ABA strategies include reinforcement, shaping, chaining of behaviors and other behavioral strategies to build specific targeted functional skills that are important for everyday life. 13.6.1 Covered Services Behavior identification assessment – Direct contact with the recipient (and collaterals as necessary) for the purposes of identification of deficient adaptive or maladaptive behaviors, completing an evaluation of the recipient’s mental health and/or substance abuse disorder(s) to determine treatment needs and establish a treatment plan. This service may include psychological testing if indicated. Observational behavioral follow-up assessment – Direct contact with the recipient (and collaterals as necessary) for the purposes of identification and evaluation factors that may impede the expression of adaptive behavior. This assessment utilizes structured observation and/or standardized and nonstandardized test to determine adaptive behavior. This service may include psychological testing if indicated. Ch. 13 Index 197 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Adaptive behavior treatment – Direct contact with the recipient (and collaterals as necessary) for the purpose of addressing the patient’s specific target problems and treatment goals as defined by the assessments. Adaptive behavior treatment is based on principles including analysis and alteration of contextual events and motivating factors, stimulus-consequence strategies and replacement behavior, and monitoring of outcome metrics. Family adaptive behavior treatment guidance – Direct contact with the family/caregiver to provide specialized training and education to assist with the child’s needs and development. The provider will observe, instruct and train the family/caregivers on the child’s development status, and techniques and strategies to promote the child’s development that is established in the treatment plan. Code 0359T 0360T 0361T 0364T 0365T 0366T 0367T 0368T 0369T Ch. 13 Index Description Behavior identification assessment + plan of care. Observational Follow Up Assessment - 1st 30 minutes. Observational Follow Up Assessment - Additional 30 minutes. Behavior treatment by protocol administered by technician first 30 minutes. Taxonomy Allowed Limits 103K00000X Twice A Year 103K00000X 30 Minutes 103K00000X 30 Minutes 106E00000X, 106S00000X, 103K00000X 30 Minutes Behavior treatment by protocol administered by technician each additional 30 minutes. 106E00000X, 106S00000X, 103K00000X 30 Minutes Group behavior treatment by protocol administered by technician first 30 minutes. Group behavior treatment by protocol administered by technician additional 30 minutes / Group. Behavior treatment with protocol modification administered by physician or other qualified health care professional first 30 minutes. Behavior treatment with protocol modification administered by physician or other qualified health care professional each additional 30 minutes. 106E00000X, 106S00000X, 103K00000X 30 Minutes 106E00000X, 106S00000X, 103K00000X 30 Minutes 103K00000X Quarterly 103K00000X 30 Minutes 198 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Code Description Family behavior treatment guidance administered by qualified health care professional 60 - 75 min. Family behavior treatment guidance administered by qualified health care professional 60 - 75 min. / Group. 0370T 0371T 13.6.2 Taxonomy Allowed Limits 103K00000X 60-75 Minutes 103K00000X 60-75 Minutes Applied Behavior Analysis Providers Applied Behavior Analysis Providers must follow the requirements set by the Board of Certified Behavior Analysts as per http://bacb.com/credentials/ in order to provide applied behavior analysis treatment services to Wyoming Medicaid clients. Abbreviation and Requirements Name Board Certified Behavior Analysts – Doctoral 103K00000X Board Certified Behavior Analysts 103K00000X Board Certified Assistant Behavior Analyst 106E00000X Registered http://bacb.com/credentials/ BCBA-D Be actively certified as a BCBA in Good Standing Have earned a degree from a doctoral program accredited by the Association for Behavior Analysis International or; A certificant whose doctoral training was primarily behavior-analytic in nature, but was not obtained from an ABAI-accredited doctoral program, may qualify for the designation by demonstrating that his or her doctoral degree met the following criteria: (a.)The degree was conferred by an acceptable accredited institution; AND (b.) The applicant conducted a behavior-analytic dissertation, including at least 1 experiment; AND (c.) The applicant passed at least 2 behavior analytic courses as part of the doctoral program of study; AND (d.) The applicant met all BCBA coursework requirements prior to receiving the doctoral degree. BCBA Option 1 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate coursework in behavior analysis, and a defined period of supervised practical experience to apply for the BCBA examination. Option 2 requires an acceptable graduate degree from an accredited university, completion of acceptable graduate coursework in behavior analysis that includes research and teaching, and supervised practical experience to apply for BCBA examination. Option 3 requires an acceptable doctoral degree that was conferred at least 10 years ago and at least 10 years post-doctoral practical experience to apply for the BCBA examination. BCaBA 1. Degree Applicant must possess a minimum of a bachelor’s degree from an acceptable accredited institution. The bachelor’s degree may be in any discipline. 2. Coursework Course work must come from an acceptable institution and cover the required content outlined in the BACB’s Fourth Edition Task List and Course Content Allocation documents. 3. Experience Applicants must complete experience that fully complies with all of the current Experience Standards. 4. Examination Applicants must take and pass the BCaBA examination. RBT Ch. 13 Index 199 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Behavior Technician 106S00000X 13.7 1. Age and Education RBT applicants must be at least 18 years of age and have demonstrated completion of high school or equivalent/higher. 2. Training Requirement The 40-hour RBT training is not provided by the BACB but, rather, is developed and conducted by BACB certificants. 3. The RBT Competency Assessment The RBT Competency Assessment is the basis for the initial and annual assessment requirements for the RBT credential. 4. Criminal Background Registry Check To the extent permitted by law, a criminal background check and abuse registry check shall be conducted on each RBT applicant no more than 45 days prior to submitting an application. 5. RBT Examination All candidates who complete an RBT application on or after December 14, 2015 will need to take and pass an examination before credential is awarded. Limitations for Behavioral Health Services The report writing segment, for the purpose of compiling a formal report of psychological test findings, is limited to a maximum of three (3) hours. Span billing is not allowed for fee for service behavioral health services. Each date of service must be billed on its own separate line. The following conditions do not meet the medical necessity guidelines, and therefore will not be covered: Clients age 21 and over are limited to restorative/rehabilitative services only. 13.8 Restorative/rehabilitative services are services that assist an individual in regaining or improving skills or strength. Maintenance therapy can be provided for clients age 20 and under. Services are not medically necessary. Treatment whose purpose is vocationally or recreationally based. Diagnosis or treatment in a school-based setting. Cap Limits Medicaid clients age 21 and over will be limited to 20 behavioral health service visits per year. If the client has exceeded the Medicaid limits on behavioral health visits, the provider may bill him/her, or request the cap limit be waived, as long as the services are still medically necessary (6.9, Cap Limits). 13.9 Documentation Requirements for All Behavioral Health Providers Ch. 13 Index 200 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ 13.9.1 Provider Agreement The Provider Agreement requires that the clinical records fully disclose the extent of treatment services provided to Medicaid clients. The following elements are a clarification of Medicaid policy regarding documentation for medical records: The record shall be typed or legibly written. The record shall identify the client on each page. Entries shall be signed and dated by the qualified staff member providing service. A mental health/substance use therapeutic record note must show length of service including time in and time out (Standard or Military time). The record shall contain a preliminary working diagnosis and the elements of a history and mental status examination upon which the diagnosis is based. All services, as well as the treatment plan, shall be entered in the record. Any drugs prescribed by medical personnel affiliated with the provider, as part of the treatment, including the quantities and the dosage, shall be entered in the record. The record shall indicate the observed mental health/substance abuse therapeutic condition of the client, any change in diagnosis or treatment, and client’s response to treatment. Progress notes shall be written for every contact billed to Medicaid. The record must include a valid consent for treatment signed by the client or guardian. Pursuant to Wyoming Medicaid Rules, Chapter 3-Provider Participation, “Documentation requirements,” a provider must have completed all required documentation, including required signatures, before or at the time the provider submits a claim to the Division (Division of Healthcare Financing, Medicaid). Documentation prepared or completed after the submission of a claim will be deemed to be insufficient to substantiate the claim and Medicaid funds shall be withheld or recovered. 13.9.2 Documentation of Services Documentation of the services must contain the following: Name of the client Identify the covered services provided and the procedure code billed to Medicaid Identify the date, length of time (start and end times in standard or military format), and location of the service Identify all persons involved Be legible and contain documentation that accurately describes the services rendered to the client and progress towards identified goals Ch. 13 Index 201 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Full signature, including licensure or certification of the treating provider involved Providers shall not sign for a service prior to the service being completed No overlapping behavioral health services NOTE: When providing behavioral health services to a Medicaid client, the documentation kept must be accurate with the date and times the services were rendered (3.11 Record Keeping, Retention and Access, 13.9 Documentation Requirements for All Behavioral Health Providers). Behavioral health services cannot overlap date and time for a client. For example, a client being seen for group therapy on February 28th from 11:00 to 12:00 cannot also be seen for targeted case management on February 28th from 11:00 to 12:00. These are overlapping services and cannot be billed to Medicaid. The importance of proper documentation of services is important to differentiate the times of services being rendered, as you cannot bill times on a CMS 1500. 13.9.3 Client Records Providers of mental health/substance use services under the Medicaid shall maintain clinical and financial records in a manner that allows verification of service provision and accuracy in billing for services. Billed services not substantiated by clinical documentation shall be retroactively denied payment. The provider shall be responsible for reimbursing any Medicaid payments that are denied retroactively. Late entries made to the client’s record are allowable to supplement the clinical record. Late entries are not allowable for the purpose of satisfying record keeping requirements after billing Wyoming Medicaid. 13.9.3.1 Requirements In addition to the general documentation requirements listed above, the following requirements shall be met: There shall be a separate clinical note made in each client’s clinical record for every treatment contact that is to be billed to Medicaid. More frequent documentation is acceptable and encouraged o A separate progress note in the clinical record for each face-to-face contact with the client and with others who are collaterals to implement the client’s treatment plan. Progress notes shall include: The name of the Medical reimbursable service rendered and procedure code billed to Medicaid The date, length of time (time in and time out in standard or military time format) and location of the contact Persons involved (in lieu or in addition to the client) Summary of client condition, issues addressed, and client progress in meeting treatment goals Signature, date and credentials of treating staff member o The note for Psychosocial Rehabilitation shall document: Ch. 13 Index 202 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ The date and length of time (time in and time out in standard or military time format) of each day’s contact A separate progress note describing therapeutic activities provided, the procedure code billed to Medicaid, and client’s progress in achieving the treatment goal(s) to be accomplished through psychosocial rehabilitation Signature, date and credentials of treating staff member Co-signature of the primary therapist on progress notes for services provided by non-licensed, certified staff or qualified case managers o Individual Rehabilitative Services (IRS), a separate chart note shall document each contact to be billed, including: The date and length of time (time in and time out in standard or military time format) of each day’s contact Activities of the skill trainer and activities of the client Any significant client behavior observed The date and signature of the skill trainer The location of service and the procedure code billed to Medicaid The signature, date and credentials of the primary therapist o Peer Specialist Services, a separate chart note shall document for each contact to be billed, including: The date and length of time (time in and time out in standard or military time format) of each day’s contact Activities of the skill trainer and activities of the client Any significant client behavior observed The date and signature of the skill trainer The location of service and the procedure code billed to Medicaid The signature, date and credentials of the primary therapist o Ongoing Case Management Services and Targeted Case Management Services, a separate chart note shall document each contract to be billed, including: The date and length of time (time in and time out in standard or military time format) of each day’s contact The date and signature of the case manager Type and description of each service and the procedure code billed to Medicaid Each note shall show length of service, time in and time out in standard or military format. The provider shall adhere to clinical records standards defined in Section 3.5. The provider shall maintain an individual ledger account for each Medicaid client who receives services. The ledger account shall indicate, at a minimum: o The length of contact rounded to the nearest 15- minute unit, per billing instructions. If seven (7) minutes or less of the next fifteen (15) Ch. 13 Index 203 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ minute unit is utilized, the unit must be rounded down. However, if eight (8) or more minutes of the next fifteen (15) minute unit are utilized, the units can be rounded up. Date ranges are not acceptable. O The date and type of each treatment contact. o The appropriate Medicaid charge. o Date that other third-party payers were billed and the result of the billing. Services noted on the individual ledger account and billed to Medicaid shall be substantiated by the clinical record documentation. 13.9.3.2 Clinical Records Content Requirement Each Medicaid provider shall establish requirements for the content, organization, and maintenance of client records. The content of clinical records shall include, at a minimum: Documentation of client consent to treatment at the agency. If an adult client Ch. 13 Index is under guardianship, consent shall be obtained from the guardian. In the case of minors, consent shall be obtained from a parent or the guardian. Wyoming Medicaid shall not reimburse for services delivered before a valid consent is signed. A client fee agreement, signed by the client or guardian. For Medicaid, this agreement shall include authorization to bill Medicaid, and other insurance if applicable, using the following statement, “I authorize the release of any treatment information necessary to process Medicaid/insurance claims.” A specific fee agreement for any Medicaid non-covered service, and the fee that an enrolled client agrees to pay. Documentation that each client has been informed of his or her client rights. A clinical assessment completed prior to the provision of treatment services which shall include at a minimum: o The specific symptoms/behaviors of a mental/substance use disorder which constitute the presenting problem. o History of the mental/substance use disorder and previous treatment. o Family and social data relevant to the mental/substance use disorder. o Medical data, including a list of all medications being used, major physical illnesses, and substance use (if not the presenting problem). o Mental status findings. o A diagnostic interpretation. o A DSM (current edition) diagnosis A diagnostic interpretation or a treatment plan shall be completed prior to or within five (5) working days of the third face-to-face contact with a licensed mental health professional. Properly executed release of information, as applicable, and chart documentation of information received or released as a result of the written client consent. 204 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Testing, correspondence, and like documents or copies. For any client receiving ten or more therapeutic contacts, a discharge summary which includes each type of Medicaid service received client progress in achieving treatment goals, and plans for follow-up, necessary. The discharge summary shall be completed within 90 days of the last contact. Any clinical record shall document the reason for case closure. 13.9.4 Treatment Plans Treatment plans for services must be based on a comprehensive assessment of an individual’s rehabilitation needs, including diagnoses and presence of a functional impairment in daily living, and be reviewed every 90-days. Treatment plans must also: Be developed by qualified provider(s) working within the State scope of 13.9.5 practice acts with significant input from the client, client’s family, the client’s authorized healthcare decision maker and/or persons of the client’s choosing; Ensure the active participation of the client, client’s family, the client’s authorized healthcare decision maker and/or persons of the client’s choosing in the development, review and modification of these goals and services; Specify the client’s rehabilitation goals to be achieved, including recovery goals for persons with mental health and/or substance related disorders; Specify the mental health and/or substance related disorder that is being treated; Specify the anticipated outcomes within the goals of the treatment plan; Indicate the type, frequency, amount and duration of the services; Be signed by the individual responsible for developing the rehabilitation plan; Specify a timeline for reevaluation of the plan, based on the individual’s assessed needs and anticipated progress, but not longer than 90-days; Document that the individual or representative participated in the development of the plan, signed the plan, and received a copy of the rehabilitation plan; and Include the name of the individual; and The date span of services the treatment plan covers; and The progress made toward functional improvement and attainment of the individual’s goals. Billing Requirements In order to obtain Medicaid reimbursement for services, the following standards must be observed. The services must be medically necessary and follow generally accepted standards of care. Ch. 13 Index 205 Revision 4/1/17 Covered Services –_Behavioral Health_____________________________________________ Bill using the appropriate code set. The service must be a service covered by Medicaid. Claims must be made according to Medicaid billing instructions. 13.9.6 Time and Frequency Time and frequency are required on all documentation and must be specific so time in and time out must be reflected on the document in standard or military format. Time can be a unit of 15 minutes depending on the Current Procedural Terminology (CPT) code or Healthcare Common Procedure Coding System (HCPCS) Level II code used to bill the service. For example, if the code is a fifteen (15) minute unit, then follow the guidelines for rounding to the nearest unit. If seven (7) minutes or less of the next 15 minute unit is utilized, the unit must be rounded down. However, if eight (8) or more minutes of the next 15 minute unit are utilized, the units can be rounded up. Date ranges are not acceptable. Please refer to the CPT and HCPCS coding books for more information on how to round a unit per code. 13.9.7 Pre-Admission Screening and Resident Review (PASRR) Assessments 13.9.7.1 Billing Requirements Submit PASRR Level II claims to the Medicaid Program. PASRR Level II assessments should be sent to WYhealth (2.1, Quick Reference). PASRR Level II Billing Code(s) HCPCS Level II Code 1 Unit Equals Description T2011 Per Visit PASRR Level II Psychiatrist Ch. 13 Index 206 Taxonomies Allowed 101Y00000X, 101YP2500X, 103G00000X, 103TC0700X, 1041C0700X, 106H00000X, 20 (Physicians), 2084P0800X, 364SP0808X Revision 4/1/17 Covered Services – Children’s Mental Health Waiver________________________________ Chapter Fourteen – Covered Services – Children’s Mental Health Waiver 14.1 Children’s Mental Health Waiver (CMHW) Services as Administered by Magellan healthcare, Inc., Through the Care Management Entity ................... 208 14.2 Child and Adolescent Service Intensity Instrument (CASII) Evaluations ........ 208 14.2.1 Requirements ..................................................................................................... 208 14.2.2 Billing Requirements ......................................................................................... 209 Ch. 13 Index 207 Revision 4/1/17 Covered Services – Children’s Mental Health Waiver________________________________ 14.1 Children’s Mental Health Waiver (CMHW) Services as Administered by Magellan Healthcare, Inc., Through the Care Management Entity The Care Management Entity (CME) is a short-term home and community based program that utilizes an intensive care coordination model (high fidelity wraparound) designed to provide a community-based alternative for youth with serious emotional disturbance who might otherwise be hospitalized and whose parents may be required to relinquish custody of their child in order for them to receive needed mental health treatment and services. The Children’s Mental Health Waiver via the CME seeks to (1) prevent custody relinquishment in order for youth to receive mental health treatment; (2) prevent or reduce the length of costly psychiatric hospital stays; and (3) provide a mechanism to offer mental health support services to youth with serious emotional disturbance and their families in identified service areas. The Children’s Mental Health Waiver is not a long-term care waiver. Children who are not financially eligible for Medicaid and who meet the clinical eligibility criteria for Care Management Entity (CME) services may apply for CME participation through the CMHW. For additional information on the CME contact Magellan at: 1-855-883-8740 TDD/TTY: 1-800-424-6259 http://www.magellanofwyoming.com To apply for participation in the CME through the Children’s Mental Health Waiver please refer to the Children’s Mental Health Waiver website at: https://health.wyo.gov/healthcarefin/medicaid/childrens-mental-health-waiver/ 14.2 Child and Adolescent Service Intensity Instrument (CASII) Evaluations CASII evaluations are performed for waiver applicants initially as a step in the eligibility process in order to receive waiver services, then again every 12-months for re-certification. 14.2.1 Requirements Reimbursement for CASII evaluations will be made to providers approved by the Children’s Mental Health Waiver program, and only after all billing requirements are met. Ch. 13 Index 208 Revision 4/1/17 Covered Services – Children’s Mental Health Waiver________________________________ 14.2.2 Billing Requirements Upon completion of the CASII the provider must submit the following documentation to the Children’s Mental Health Waiver staff: o CASII scoring sheet– completed and signed. o CASII instrument identifying selected letter items for each numbered anchor point. o Waiver services application. Claims cannot be submitted for at least 72-hours after all required documentation is sent to Children’s Mental Health. Clients who are not eligible for any other Medicaid plan will be made eligible for the date of the CASII evaluation for the processing of these claims. The CASII score sheet needs to contain the following information to add the client to the system for claims payment: o Client Name. o Address. o Social Security Number. o Date of Birth. All services billed in relation to the CASII evaluation will be billed on a single date of service. This date should be the date listed with the evaluators’ signature on the submitted forms. o Example – The CASII evaluation process was conducted on August 1, August 8, and August 9. The CASII evaluation was signed and submitted on August 9 therefore one (1) unit will be billed with a date of service of August 9. CASII Evaluation Procedure Codes Code Modifier(s) H0002 1 Unit Equals Procedure Quantity Description 1 evaluation 1 Max Unit CASII Evaluation CASII evaluators, who assist the client and/or their family to complete the full Care Management Entity (CME) enrollment packet, including completion of the application and assistance with arranging completion of the level of care form, may add the modifier “CG” to the procedure code H0002 for a reimbursement increase of 25%. Supporting documentation for the use of modifier CG with procedure code H0002 includes an accurately completed ECSII or CASII evaluation, a completed CME application, and a completed level of care form submitted to and accepted by the CME. Ch. 13 Index 209 Revision 4/1/17 Covered Services –_Chiropractic Services__________________________________________ Chapter Fifteen – Covered Services – Chiropractic Services 15.1 Coverage Indications ......................................................................................... 211 15.2 Definitions ......................................................................................................... 211 15.3 Medical Necessity ............................................................................................. 211 15.4 Limitations......................................................................................................... 212 15.5 Covered CPT Codes .......................................................................................... 212 15.6 Documentation Requirements ........................................................................... 213 Ch. 15 Index 210 Revision 4/1/17 Covered Services –_Chiropractic Services__________________________________________ 15.1 Coverage Indications Coverage of chiropractic service is specifically limited to treatment by means of manual manipulation, i.e., by use of the hands. Manual devices (i.e., those that are hand-held with the thrust of the force of the device being controlled manually) may be used by chiropractors in performing manual manipulation of the spine, however, no additional payment is available for use of the device, nor does Medicaid recognize an extra charge for the device itself. The word "correction" may be used in lieu of "treatment." The following terms, or combination of may be used to describe manual manipulation as defined above: 15.2 Spine or spinal adjustment by manual means; Spine or spinal manipulation; Manual adjustment; and Vertebral manipulation or adjustment. Definitions Acute: A patient's condition is considered acute when the patient is being treated for a new injury, identified by x-ray or physical exam as specified above. The result of chiropractic manipulation is expected to be an improvement in or arrest of the progression of the patient's condition. Maintenance therapy: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. Maintenance therapy is not a Wyoming Medicaid covered service. 15.3 Medical Necessity ALL of the following criteria must be met to substantiate medical necessity: 1. The client has a neuromusculoskeletal disorder. 2. The medical necessity for treatment is clearly documented. 3. Improvement is documented within the initial two (2) weeks of chiropractic care. The service will NOT be considered medically necessary if: 1. No improvement is documented within the initial two (2) weeks unless the treatment is modified. Ch. 15 Index 211 Revision 4/1/17 Covered Services –_Chiropractic Services__________________________________________ 2. No improvement is documented within 30-days despite modification of chiropractic treatment. 3. The maximum therapeutic benefit has been achieved. 4. The chiropractic manipulation is being performed in asymptomatic person or persons without an identifiable clinical condition. 5. The chiropractic care is occurring in persons whose condition is neither regressing nor improving. 15.4 Limitations Evaluation & Management (E & M) Cap Limits: Medicaid clients 21 years of age and older are subject to a service cap limit of 12 office/outpatient hospital visits per calendar year. This includes all E & M procedure codes. Chiropractic Services Cap Limits: Medicaid clients are subject to a service cap limit of 20 chiropractic visits per calendar year. 15.5 Covered CPT Codes 99201-99205, 99211-99215 These office visit codes are subject to a $2.45 co-pay for adults >21 years of age. A full schedule of co-pays and exceptions is located in Chapter 6 of the CMS 1500 Manual. 98940, 98941, 98942 70100 -77086 Diagnostic Radiology codes Refer to the Wyoming Medicaid CMS 1500 Manual for additional information regarding radiology services. Some diagnostic radiology services require prior authorization. A complete list of codes and requirements may be viewed at WYhealth or by contacting (888)545-1710 prompt 4. Ch. 15 Index 212 Revision 4/1/17 Covered Services –_Chiropractic Services__________________________________________ 15.6 Documentation Requirements 1. History as stated above. 2. Description of the present illness including: Mechanism of trauma. Quality and character of symptoms/problem. Onset, duration, intensity, frequency, location, and radiation of symptoms. Aggravating or relieving factors. Prior interventions, treatments, medications, secondary complaints. Symptoms causing client to seek treatment. These symptoms must bear a direct relationship to the level of subluxation. The symptoms should refer to the spine (spondyle or vertebral), muscle (myo), bone (osseo or osteo), rib (costo or costal) and joint (arthro), and be reported as pain (algia), inflammation (itis), or as signs such as swelling, spasticity, etc. Vertebral pinching of spinal nerves may cause headaches, arm, shoulder, and hand problems as well as leg and foot pains and numbness. Rib and rib/chest pains are also recognized symptoms, but in general other symptoms must relate to the spine as such. The subluxation must be causal, i.e., the symptoms must be related to the level of the subluxation that has been cited. A statement in the client's file/chart that there is "pain" is insufficient. The location of pain must be described and whether the particular vertebra listed is capable of producing pain in the area determined. 3. Evaluation of musculoskeletal/nervous system through physical examination. 4. Diagnosis (ICD-10 diagnosis codes will be required for dates of service 10/1/2015 and after): The primary diagnosis must be subluxation, including the level of subluxation, either so stated or identified by a term descriptive of subluxation. Such terms may refer either to the condition of the spinal joint involved or to the direction of position assumed by the particular bone named. 5. Treatment Plan: The treatment plan should include the following: Recommended level of care (duration and frequency of visits). Specific treatment goals. Objective measures to evaluate treatment effectiveness. 6. Date of the initial treatment. Ch. 15 Index 213 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ Chapter Sixteen – Covered Services – Developmental Centers 16.1 Development Centers ........................................................................................ 215 16.2 General Documentation Requirements ............................................................. 215 16.3 Location ............................................................................................................. 215 16.4 Time and Frequency .......................................................................................... 215 16.5 Missed Appointments/Make-up Session ........................................................... 216 16.6 Diagnosis ........................................................................................................... 216 16.7 Covered Services ............................................................................................... 216 16.8 Billing Requirements ......................................................................................... 218 Ch. 16 Index 214 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ 16.1 Development Centers A developmental center is a public or privately funded facility, which provides services to clients (infants/toddlers or preschool age children, ages 0-5) with developmental disabilities who have been determined to require early intervention programs, care, treatment and supervision in an appropriate setting. A licensed practitioner is a person that is licensed within the state of Wyoming to perform specialized services (e.g., physician or nurse practitioner). 16.2 General Documentation Requirements The Provider Agreement requires that medical records fully disclose the extent of services provided to Medicaid clients. The following elements are a clarification of Medicaid policy regarding documentation for medical records (3.11.1, Requirements): The record must be typed or legibly written. The record must identify the client on each page. The record must contain a preliminary working diagnosis and the elements of a clinical assessment upon which the diagnosis is based. All services, as well as the treatment plan, must be entered in the record. The record must indicate the observed condition of the client, the progress at each visit, any change in diagnosis of treatment, and the client’s response to treatment. Progress notes must be written for every service billed to Medicaid. The type, frequency and duration of service must be specified in the treatment plan. All services provided must track back to the client’s treatment plan. 16.3 Location If the location on the physician’s order is different from the location where the child is seen, the therapist must document the deviation from the Plan of Care in the child’s record. If this occurs on a regular basis, there must be a modification of the Plan of Care. 16.4 Time and Frequency Time and frequency are required on the physician’s order and must be specific so time in and time out must be reflected on the document in standard or military format. Time is a unit of 15 minutes. If seven (7) minutes or less of the next 15 minute unit is utilized, the unit must be rounded down. However, if eight (8) or more minutes of the Ch. 16 Index 215 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ next 15 minute unit are utilized, the units can be rounded up. Date ranges are not acceptable. For example, six (6) months duration three (3) times per day is an acceptable time and frequency. 16.5 Missed Appointments/Make-up Session Medicaid clients have the right to refuse services. If numerous therapy sessions are missed, the therapist may offer make-up sessions; however, if the child is continually non-compliant with attendance for whatever reason, the practitioner must be informed of the missed sessions and non-compliance of the child. All communication with the child, child’s family and practitioner must be documented in the child’s records. Clients should be seen for the amount of time and frequency noted on the physician’s order. An extra session may be billed only if the need for a make-up session is documented within the record. Billing cannot exceed the Plan of Care. 16.6 Diagnosis When billing Medicaid for services provided at Developmental Centers, the diagnosis codes used must be: Consistent with the diagnosis identified by the ordering practitioner; Related directly to the need for the services billed; and Coded to the greatest degree of specificity. Developmental Centers may not assign diagnosis codes. Diagnosis codes must be provided by the practitioner or healthcare provider. 16.7 Covered Services Diagnostic Evaluations/Assessments – A comprehensive multi-disciplinary evaluation performed by an appropriate Wyoming certified or licensed practitioner is required for all children referred and all areas will be evaluated to gain a complete developmental overview of the child. o Areas to be assessed will include physical development including fine and gross motor skills, cognitive development, speech development, and social and emotional development. o Service is limited to children five (5) years of age and under. o A licensed practitioner shall provide diagnostic evaluation services. o Must have a written referral and the referral must list areas of concern. o Use standardized assessment tools or criterion based assessment. o Written report includes: Assessment tools used Ch. 16 Index 216 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ NOTE: Procedures followed Findings of the evaluation/assessment shall be developed Provide a copy to the referring practitioner Based on the individual needs of the child, the evaluation may take place in a Regional Developmental Center, the child’s primary placement (if other than a Developmental Center) or the child’s home. Mental Health Services – Medicaid will pay for mental health services provided by licensed mental health professionals at a Developmental Center to include licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), licensed clinical social workers (LCSW), licensed addiction therapists (LAT), and provisional licensed mental health professionals under the supervision of a licensed mental health professional. Physical, Occupational, and Speech Therapy – Medicaid covers restorative therapy services when provided by or under the direct supervision of a licensed physical, occupational or speech therapist upon written orders from a practitioner. o Restorative services are services that assist an individual in regaining or improving skills or strength. o Speech therapy includes any therapy to correct a speech disorder resulting from injury, trauma, or a medically based illness or disease. o Service is limited to children five (5) years of age and under o Therapy shall be provided only after a written order is received from a licensed practitioner o Group therapy or field trips cannot exceed five (5) children o If “individual” is indicated on the Physician’s Order and the child is seen in a group session, the therapist may not bill for a group session for that child. Specific Documentation Requirements – Prior to providing any therapy services, the following must occur and be documented in the client’s permanent clinical record: o A comprehensive medical diagnostic examination by a licensed practitioner as well as a multi-disciplinary comprehensive evaluation must be completed as part of the Individual Education Plan/Individual Family Services Plan (IEP/IFSP). The IFSP must be completed for children ages 0-36 months. o Services must: Be determined, in writing, to be medically necessary by a licensed practitioner; Appear on the practitioner’s plan of treatment/care; and Have original and subsequent renewal written orders, not to exceed six (6) months duration. o The practitioner’s plan of treatment/care shall contain: Ch. 16 Index 217 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ Diagnosis and onset date of client’s condition; Client’s rehabilitation potential; Restorative and/or maintenance program goals; Therapy modalities determined to be medically necessary to attain the program goals; Therapy duration (not to exceed six (6) months); and Practitioner’s signature and date signed. o Each therapy ordered, either independently or in combination, must: State treatment goals in terms of specific outcomes associated with referral diagnosis; Outline each therapy regime relative to stated goals, including modalities, frequency of each treatment session and duration of each treatment session; Be updated with every change or renewal of physician orders (not to exceed six (6) months); Be signed, including professional title, and dated by each appropriate therapist; and Be attached to the client’s IEP/IFSP. o Ongoing documentation of services provided (progress notes) is required by each type/discipline of therapy billing Medicaid for services provided and shall include each of the following: Identification of the client on each page of the treatment record; Identification of the type/discipline of therapy being documented on each entry (i.e., speech vs. occupational therapy); Date and time(s) spent in each therapy session; Description of therapy activities, client reaction to treatment and progress being made to stated goals/outcomes; and Full signature or counter signature of the licensed therapist, professional title and date that entry was made and the signature of the therapy assistant and date the entry was made. Licensed therapist must sign progress notes of assistants within 30-days. 16.8 Billing Requirements The following procedure codes can be billed by enrolled Developmental Centers: Developmental Centers HCPCS Level II Code 92507 Ch. 16 Index Modifier 1 Unit Equals Per Instance Description Individual treatment of speech language voice communication and/or auditory processing disorder 218 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ Developmental Centers HCPCS Level II Code 92508 92521 92522 92523 92524 92526 97001 97002 97003 97004 Modifier 1 Unit Equals Per Instance Per Evaluation Per Evaluation Per Evaluation Per Evaluation Per Instance Per 15 minutes Per 15 minutes Per 15 minutes Per 15 minutes 97110 Per 15 minutes 97112 Per 15 minutes 97113 Per 15 minutes 97124 Per 15 minutes 97150 97530 Ch. 16 Index Per 15 minutes Per 15 minutes Description (including aural rehab). Treatment of speech, language, voice communication, and/or auditory processing disorder (including aural rehab); group, two (2) or more individuals. Evaluation of speech fluency. Evaluation of speech fluency. Evaluation of speech sound production with evaluation of language comprehension and expression. Behavioral and qualitative analysis of voice and resonance. Treatment of swallowing dysfunction and or oral function for feeding. Physical therapy evaluation. Physical therapy re-evaluation. Occupational therapy evaluation. Occupational therapy re-evaluation. Therapeutic procedure, one (1) or more areas; therapeutic exercises to develop strength and endurance, range of motion and flexibility. Therapeutic procedure, one (1) or more areas; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities. Therapeutic procedure, one (1) or more areas; aquatic therapy with therapeutic exercises. Therapeutic procedure, one (1) or more areas; massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion). Therapeutic procedure(s); group, two (2) or more individuals. Therapeutic activities, direct (one to one) client contact by the provider. 219 Revision 4/1/17 Covered Services –_Developmental Centers________________________________________ Developmental Centers HCPCS Level II Code Modifier 1 Unit Equals 97533 Per 15 minutes G9012 Per 15 minutes H0031 Per 15 minutes H2019 Per 15 minutes H2019 HQ Per 15 minutes H2021 Per 15 minutes T2011 N/A Description Sensory integrative techniques to enhance sensory processing and promote adaptive responses of environmental demands, direct (one-on-one) client contact by the provider. Other specified case management service not elsewhere classified. Clinical assessment – Therapist contact with the client and/or collaterals as necessary, for the purpose of completing an evaluation of the client’s mental health and substance abuse disorder(s) and treatment needs, including psychological testing if indicated. Agency Based Individual/Family Therapy – Therapist contact at the developmental center with the enrolled client and/or collaterals as necessary, for the purpose of developing and implementing the treatment plan for the enrolled client. Group Therapy – Therapist contact with two (2) or more unrelated clients and/or collaterals as necessary, for the purpose of implementing each client’s treatment plan. Community-Based Individual/Family Therapy – Therapist contact outside the developmental center with the enrolled client and/or collaterals as necessary, for the purpose of developing and implementing the treatment plan for the enrolled client. PASRR Level II Developmental Disabilities Evaluation. Developmental Centers Modifier Description HI Multi-Disciplinary Team HQ Group Setting Ch. 16 Index 220 Revision 4/1/17 Covered Services –_Dietician_____________________________________________________ Chapter Seventeen – Covered Services – Dietician 17.1 Limitations......................................................................................................... 222 17.2 Covered CPT Codes and Documentation .......................................................... 222 17.3 Medical Nutrition Therapy Documentation Requirements ............................... 222 Ch. 17 Index 221 Revision 4/1/17 Covered Services –_Dietician_____________________________________________________ 17.1 Limitations Dietician services must be ordered by a physician or nurse practitioner. Medicaid clients are subject to a service cap limit of 20 visits per calendar year. 17.2 Covered CPT Codes and Documentation 97802 – Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes – Maximum allow 4 units per day. 97803 – Medical nutrition therapy; re-assessment and intervention, individual, face to-face with the patient, each 15 minutes – Maximum allow 4 units per day. 97804 – Medical nutrition therapy; group (2 or more individual(s)), each 30 minutes – Maximum 2 units per day. 17.3 Medical Nutrition Therapy Documentation Requirements For Medical Nutrition Therapy, the following elements must be in the documentation: 1. Date of MNT visit along with Beginning and Ending Time of visit; 2. ICD-10 code – defines type of visit/counseling; 3. Subjective Data: a. Client’s reason for visit b. Primary care physician c. History i. Past and present medical ii. Nutrition including food patterns and intake iii. Weight iv. Medication v. Exercise 4. Objective Data: a. Laboratory results (if available) b. Height, Weight c. BMI d. Calorie Needs e. Drug/Nutrient Interactions 5. Individual Assessment of Diet/Intake: a. Laboratory results (if available) b. Height, Weight c. BMI d. Calorie Needs e. Drug/Nutrient Interactions 6. Plan: Ch. 17 Index 222 Revision 10/1/16 Covered Services –_Dietician_____________________________________________________ a. Individualized dietary instruction that incorporates diet therapy counseling and education handouts for nutrition related problem. b. Plan for follow-up. c. Documentation of referral for identified needs. d. Send a letter to the client’s physician describing dietary instruction provided and progress. A copy of the letter should be placed in the client’s medical record. 7. Date and legible identity of provider: a. All entries must be signed and dated by the provider. Ch. 17 Index 223 Revision 10/1/16 Covered Services –_DME Billing_________________________________________________ Chapter Eighteen – Covered Services – DME Billing 18.1 Order vs Delivery Date...................................................................................... 225 18.2 DME Billing Requirement Exception ............................................................... 225 18.2.1 Ch. 18 Index K0108/E1399 Crossover Claim Form ............................................................... 227 224 Revision 4/1/17 Covered Services –_DME Billing_________________________________________________ 18.1 Order vs Delivery Date If the client is not eligible on the delivery date or does not return for the delivery, the provider may submit an “Order vs Delivery Date Exception Form” for authorization to bill on the order date. (6.14 Order Vs Delivery Date) 18.2 DME Billing Requirement Exception For clients who are dual eligible Medicare and Medicaid, in situations where the provider is billing for multiple units of either K0108 or E1399, and Medicare approves some units but not all units, the provider may complete the billing requirements and exception process/steps below for additional Medicaid reimbursement, if applicable. The Medicaid claim will be processed according to Wyoming Medicaid’s policy for the units Medicare denied. NOTE: K0108 and E1399 only and the client is dual eligible, Medicare and Medicaid. Refer to the DME Covered Services manual and Chapters 1-10 of this manual for the complete Medicaid policy. Provider must obtain a prior authorization (PA) through the Medicaid DME vendor 1. Submit the claim first to Medicare according to Medicare instructions. 2. Medicare should crossover the claim electronically to Medicaid, and any units approved by Medicare will be processed to pay co-insurance and deductible as per usual. Lines that Medicare denied will deny on the crossover claim as exact duplicates conflicting with the paid lines of the same code, but the crossover claim will be in a paid status. a. If crossover claim is not received electronically from Medicare the providers will need to submit this crossover claim electronically to Medicaid (Refer to the Web Portal Tutorials) 3. Providers need to wait for the paid crossover to appear on the Medicaid remittance advice (RA)/835 before continuing the DME billing requirement exception process (Step 5). 4. Once the paid crossover claim appears on the Medicaid RA, the provider will need to complete a CMS-1500 paper claim form. Complete the paper claim form according to Medicaid’s billing requirements, not the way it was previously submitted to Medicare. a. Bill according to Medicaid’s PA, enter the PA number in box 23 b. All units denied by Medicare must be combined onto one line with multiple units or they will deny as exact duplicates. i. Billed charge/units must add up and match the Medicare EOMB. Ch. 18 Index 225 Revision 4/1/17 Covered Services –_DME Billing_________________________________________________ 5. Review the invoice(s) for each item and clearly mark for each line item a. Medicaid must be able to match descriptions from the PA to the invoice(s), to assist with this process complete the K0108/E1399 Crossover Claim Form (18.1.1 K0108/E1399 Crossover Claim Form) 6. Completing the K0108/E1399 Crossover Claim Form – the purpose of this form is to assist in matching up the descriptions of the items/components of the PA to the appropriate items on the invoice(s). a. When entering the first item description on line 1 of the form place (1) on the invoice next to the item on the invoice that matches it, continue the same process until all items are documented on the form. i. Complete as many forms as necessary. 7. Finalization and mailing process: Providers must include all of the following in the mailing a. K0108/E1399 Crossover Claim Form (place on top to ensure appropriate routing) b. Completed CMS-1500 paper claim form c. Medicare’s EOMB d. Invoice(s) e. Mail the documents to: Wyoming Medicaid ATTN: Medical Policy PO Box 667 Cheyenne, WY 82003-0667 Ch. 18 Index 226 Revision 4/1/17 Covered Services –_DME Billing_________________________________________________ 18.2.1 K0108/E1399 Crossover Claim Form NOTE: Ch. 18 Index Click image above to be taken to a printable version of this form. 227 Revision 4/1/17 Covered Services –_Family Planning______________________________________________ Chapter Nineteen – Covered Services – Family Planning 19.1 Family Planning Clinics .................................................................................... 229 19.2 Covered Services ............................................................................................... 229 19.3 Non-Covered Services ....................................................................................... 229 Ch. 19 Index 228 Revision 4/1/17 Covered Services –_Family Planning______________________________________________ 19.1 Family Planning Clinics Family planning clinics provide services that are prescribed to clients of childbearing age for the purpose of enabling them to freely determine the number and spacing of their children. 19.2 Covered Services The following services are covered by Medicaid: Appropriate office visits according to CPT guidelines. Contraceptive supplies and devices as prescribed by a healthcare provider 19.3 (limited to a three (3) month supply). Insertion or removal of implantable capsules are allowed with appropriate E&M procedure code. Insertion or removal of intrauterine devices (IUD’s) are allowed with an appropriate E&M procedure code. Pap smears. Pregnancy tests. Non-Covered Services The following services are not covered by Medicaid: Reversal of Sterilizations. Artificial insemination. Fertility testing. Infertility counseling. NOTE: Ch. 19 Index Pregnant by Choice/Family Planning Waiver has specific covered and non-covered services (25.1, Pregnant By Choice/Family Planning Waiver). 229 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Chapter Twenty – Covered Services – Health Check 20.1 Health Check – EPSDT ..................................................................................... 231 20.2 Periodicity Schedule .......................................................................................... 232 20.3 Reimbursement .................................................................................................. 232 20.4 Detailed Information for Well Child Screens .................................................... 236 20.5 Initial/Interval History ....................................................................................... 237 20.6 Assessments....................................................................................................... 237 20.7 Comprehensive Unclothed Physical Examination ............................................ 238 20.8 Head Circumference .......................................................................................... 238 20.9 Blood Pressure ................................................................................................... 239 20.10 Vision Screen .................................................................................................... 239 20.11 Topical Fluoride Varnish................................................................................... 239 20.12 Hearing Screen .................................................................................................. 240 20.13 Laboratory Tests ................................................................................................ 241 20.13.1 Hematocrit and Hemoglobin ............................................................................. 241 20.13.2 Blood Lead Level .............................................................................................. 241 20.13.3 Tuberculin Screening ........................................................................................ 242 20.13.4 Urinalysis........................................................................................................... 243 20.13.5 Other .................................................................................................................. 243 20.14 Immunizations ................................................................................................... 243 20.15 Dental Screen .................................................................................................... 244 20.16 Speech and Language Screens .......................................................................... 244 20.17 Discussion and Counseling ............................................................................... 244 Ch. 20 Index 230 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ 20.1 Health Check – EPSDT The Early and Periodic, Screening, Diagnosis and Treatment Program (EPSDT): Brings comprehensive healthcare to children from birth up to and including 20-years of age who are eligible for Medicaid. Has a preventive health philosophy of discovering and treating health problems before they become disabling and far more costly to treat in terms of both human and financial resources. Examines all aspects of a child’s well-being and corrects any problems that are discovered. Is administered by the Division of Healthcare Financing (DHCF), Medicaid. EPSDT is a statewide program that provides children with comprehensive health screenings, diagnostic services, and treatment of any health problem detected. Defining each word of the program title will help explain the concept of EPSDT. Procedure Code Range: 99381-99394 Early – Well Child Screens will be performed as soon as possible in the child’s life (in case of a family already receiving assistance) or as soon as a child’s eligibility for Medicaid is established. Periodic – Means Well Child Screens will be performed at intervals established by medical, dental, and other healthcare experts. Periodic screens assure diseases or disabilities are detected in the early stages. Types of procedures performed will depend on age and health history of the child. Screening – The use of examination procedures for early detection and treatment of diseases of abnormalities. Referrals are made for those in need of specialized care. Diagnosis – The determination of the nature or cause of physical or mental disease (abnormality). A diagnosis is made through the combined use of a health history, physical, developmental and psychological evaluations, laboratory tests, and x-rays. Practitioners who complete EPSDT examinations may diagnosis and treat health problems uncovered by the screen or may refer the child to other appropriate sources for care. Treatment – Care provided by practitioners enrolled with Medicaid to prevent, correct, or ameliorate disease or abnormalities detected by screening and diagnostic procedures. Practitioners may screen, diagnosis, and treat during one (1) office visit. Ch. 20 Index 231 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ 20.2 Periodicity Schedule The periodicity schedule contains an easy reference table for Well Child Screens defined by the age of the child. Refer to the Well Child Screen Requirements table for all ages. Key: 20.3 = to be performed = to be performed for clients at risk s = subjective, by history o = objective, by a standard testing method s/o = objective at 12, 15, and 18 years old, subjective, by history for all other years. Reimbursement If an abnormality(ies) is encountered or a pre-existing problem is addressed in the process of performing preventative medicine E&M service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem oriented E&M service, then the appropriate office/outpatient code 99201-99215 should also be reported. Modifier 25 must be added to the office/outpatient code to indicate that a significant, separate identifiable E&M service was provided by the same physician on the same day as the preventative service. The appropriate preventative medicine service is additionally reported. Ch. 20 Index 232 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Well Child Screen Requirements For Ages Birth through 21 Years Old Newborn – 12 months 15 months to 4 years 5-10 years 11-21 years (up to 24 mo.) (start at 3 yrs) s s s s o o o s/o (9-12 mo) (12 mo) (24 mo) (15 m-3 yrs) (24 mo-4 yrs) History Initial/Interval Measurements Height & Weight Head circumference Blood Pressure Sensory Screening Vision Hearing Developmental / Behavioral Assessment Immunizations Health Check Immunizations Procedures Lead Screening Tuberculin Test Topical Fluoride Varnish (6–12mo) Cholesterol Screening STD Screening Pelvic Exam Anticipatory Guidance Injury Prevention Violence Prevention Sleep Positioning Counseling Nutrition Counseling (up to 6 mo) (12 mo) Dental All abnormalities detected during the Health Check exam should be referred to the appropriate specialist, including but not limited to a vision, dental and /or hearing specialist as necessary. The appropriate way to indicate that the provider has referred the child is to add Modifier 32 to the preventative service code. Ch. 20 Index 233 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ If any insignificant or trivial problem/abnormality is encountered while performing the preventative medicine E&M services, and does not require additional work, the office/outpatient code should not be reported. It is of utmost importance that the appropriate CPT, modifier and diagnosis codes are reported. For the provider’s convenience, the codes, modifiers, and diagnosis codes for EPSDT-Health Check and the most current fee schedule for the above mentioned codes are attached. Fees are subject to change without notice. At a minimum, these screenings must include, but are not limited to: Comprehensive health and developmental history. Comprehensive unclothed physical examination. Dental screening. Appropriate vision testing. Appropriate hearing testing. Appropriate laboratory test (Blood Lead Level testing is required at 12 and 24 months for all children). The most current copy of the immunization schedule may be found at http://www.cdc.gov/vaccines/schedules/index.html. Diagnosis Codes to be used when Billing for EPTSD – Well Child Checks Diagnosis Code Description Health Supervision of Foundling. Z76.1 Other Healthy Infant or Child Receiving Care. Z76.2 Z00.121, Z00.129 Routine Infant or Child Health Check. Topical Fluoride Procedure Code Modifier Description D1206 32 Topical Fluoride Varnish. Preventative Medicine Services Procedure Code Modifier Description Initial Comprehensive Preventative Medicine Age 0 through 99381 32 11 Months. 99382 32 Early Childhood Age 1-4 Years. 99383 32 Late Childhood Age 5-11 Years. 99384 32 Adolescent Age 12-17 Years. 99385 32 Age 18-20 Years. Modifier 32 Mandated Services – Referral. Ch. 20 Index 234 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Evaluation and Management Services – New Patient Procedure Code Modifier 99201 25 99202 25 99203 25 99204 25 99211 25 99212 25 99213 25 Ch. 20 Index Description Office or other outpatient visit for the E&M of a new patient requires three (3) key components: A problem focused history. A problem focused exam. Straight forward medical decision making. Office or other outpatient visit for the E&M of a new patient requires three (3) key components: An expanded focused history. An expanded focused exam. Straight forward medical decision making. Office or other outpatient visit for the E&M of a new patient requires three (3) key components: A detailed history. A detailed exam Medical decision making of low complexity. Office or other outpatient visit for the E&M of a new patient requires three (3) key components: A comprehensive history. A comprehensive exam. Medical decision making of moderate complexity. Office or other outpatient visit for the E&M of an established patient that may not require the presence of a physician. Usually the presenting problems are minimal. Typically five (5) minutes are spent performing or supervising these services. Office or other outpatient visit for the E&M of an established patient which requires at least of these three (3) components: A problem focused history. A problem focused exam. Straight forward medical decision making. Office or other outpatient visit for the E&M of an established patient which requires at least of these three (3) components: An expanded problem focused history. An expanded problem focused exam. Straightforward medical decision making. 235 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Evaluation and Management Services – New Patient Procedure Code 99214 99215 NOTE: 20.4 Modifier Description 25 Office or other outpatient visit for the E&M of an established patient which requires at least of these three (3) components: A detailed history. A detailed exam. Medical decision making of low complexity. 25 Office or other outpatient visit for the E&M of an established patient which requires at least of these three (3) components: A comprehensive history. A comprehensive exam. Medical decision making of high complexity. Please refer to the current CPT for additional information regarding preventative services. Detailed Information for Well Child Screens In some instances, Well Child Screens may not be completed at the suggested age (example: immunizations); the healthcare professional must follow recommended practices to ensure the child becomes current. Results may indicate further testing or referrals are needed. Healthcare professionals should complete tests or make referrals according to standard procedures and practices. Well Child Screens must be completed when there is no acute diagnosis applicable (i.e. otitis media). May show that a high risk factor is present based on the child’s environment, history, or test results. Healthcare professionals should proceed with required/recommended tests. Evaluation methods used may be different from what is indicated on the Well Child Screen Requirements table (example: a tuberculin test performed on a child who is nine (9) months of age because the child’s sibling had an active case of diagnosed tuberculosis). The following information contains additional guidelines to be used when performing Well Child Screens. Ch. 20 Index 236 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ 20.5 Initial/Interval History The initial/interval history should be obtained from a parent or other responsible adult who is familiar with the child’s health history. This must include, but is not limited to: Family history Details of birth, prenatal, neonatal periods Nutritional status Growth and development Childhood illness Hospitalizations Immunization history NOTE: 20.6 If a health history has been obtained previously, then update it each visit. Assessments Appropriate Developmental Screening – Providers should administer a developmental screen appropriate to the age of the child during each Well Child Screen. The following screening tools are recommended for children age birth to six (6) years: 1. Prescreening Developmental Questionnaire 2. Denver Developmental Screening Test 3. Battelle Screening Test Children five (5) years of age and older should have a general developmental assessment including gross-motor and fine-motor skills, social-emotional skills, and cognitive and self-help skills development. Results of development screens need to be considered in combination with other information gained through the history, physical examination, observations of behavior and reports of observations by the parents/caregivers. Any abnormalities detected during a Well Child Screen outside of the attending physician’s scope of practice should be referred to the appropriate specialist, including vision, dental and hearing specialists as necessary. All services provided must be medically necessary and provided in the most costeffective manner. Nutritional Screen – Providers should assess the nutritional status at each Well Child Screen through the following activities: Ch. 20 Index 237 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ o Inquire about dietary practices to identify unusual eating habits. Unusual eating habits include pica behavior, extended use of bottle feedings, or diets deficient or excessive in one (1) or more nutrients; A complete physical examination including an oral inspection; Accurate measurements of height and weight (all measurements should be plotted on the National Center for Health Statistics Growth Charts); and Screening for iron deficiency at the appropriate ages and/or intervals. NOTE: 20.7 Children with nutritional problems may be referred to a licensed nutritionist or dietician for further assessment, counseling, or education as needed. Comprehensive Unclothed Physical Examination Each comprehensive unclothed physical examination should include the following: Height measurement Weight measurement Standard body systems evaluation Observation for any signs of abuse Observation of any physical abnormality During each Well Child Screen, providers need to assess the child’s growth. All measurements should be plotted on the National Center for Health Statistics (NCHS) Growth Chart. Growth assessments should be documented in the medical record and any abnormality should be addressed as abnormal if: If a child’s height and/or weight is below the 5th percentile or above the 95th percentile; or If weight for height is below the 10th percentile or above the 90th percentile (using the weight for height graph). 20.8 Head Circumference An Occipital Frontal Head Circumference (OFHC) should be measured on each child four (4) years and younger at each Well Child Screen. This measurement should be plotted on the NCHS Growth Chart. OFHC should be reported abnormal if: It is below the 5th percentile or above the 95th percentile; Size of the head is not following a normal growth curve; or Head is grossly disproportionate to the child’s length. Ch. 20 Index 238 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Deviations in the shape of the head may warrant further evaluation and follow-up. 20.9 Blood Pressure All children three (3) years and older must have a blood pressure reading at each Well Child Screen. Measurements should be taken in a quiet environment, with the correct size cuff, and with the fourth (4th) and fifth (5th) phase Korotkoff sound noted for the diastolic pressure. Blood pressure is considered abnormal if the systolic and/or diastolic or both are above the 95th percentile. Any child with a blood pressure reading above the 95th percentile should have it repeated in 7-14 days. If the blood pressure is still elevated, the child should be rechecked again in 7-14 days. If blood pressure is elevated on the third visit, the child should receive appropriate medical evaluation and follow-up, as recommended by the American Academy of Pediatrics. 20.10 Vision Screen A vision screen appropriate to the age of the child should be conducted at each Well Child Screen. Further evaluations and proper follow up should be recommended if the following conditions are present: Infants and children who show evidence of infection, squinting, enlarged or lazy cornea, crossed eyes, amblyopia, cataract, excessive blinking, or other eye abnormality; An infant or child who scored abnormal on the fixation test, papillary light reflex test, alternate cover test, or the corneal light reflect test in either eye; Three (3) to nine (9) year old children who demonstrate a visual acuity of less than 20/40 in either eye or who demonstrate a one (1) line difference in visual acuity between the two (2) eyes within the passing range; or Children ten (10) years and older whose vision is 20/30 or worsen in either eye or who demonstrate a one (1) line difference in visual acuity between the two (2) eyes within the passing range. 20.11 Topical Fluoride Varnish Physicians can apply a topical fluoride varnish for patients who are at a moderate to high risk for dental caries: This application should be done in conjunction with EPSDT well child visits. Physician offices may bill the CPT code 99188 on the CMS-1500 form. Ch. 20 Index 239 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ Fluoride varnish application can be done up to three (3) times a year on children ages six (6) months (or when the first teeth erupt) through age three (3) years. The American Academy of Pediatric Dentistry recommends the establishment of dental home no later than 12-months of age. 20.12 Hearing Screen A hearing screen appropriate to the age of the child should be conducted at each Well Child Screen. Further evaluations and proper follow up should be recommended if one (1) of the following conditions is present: Infants and children who are positive on one (1) or more of the Eight (8) Hi Ch. 20 Index Risk register items: o Visible congenital or traumatic deformity of the ear. Congenital, such as atresia (no ear canal) or abnormally small ear canals. Traumatic deformity, collapsed canals or a deformed ear that might contraindicate presence of mold or aid. History of active drainage from the ear within previous 90-days. History of sudden or rapidly progressive hearing loss within the previous 90days possibly due to viral attack, trauma, etc. should be seen by a medical doctor immediately. Acute or chronic dizziness indicates possible problems with semi-circular canals (balance). Unilateral hearing loss of sudden or recent onset within the previous 90-days. Could be caused by mumps, virus, head trauma, Meniere's disease, and various vascular disorders. Audiometric air-bone gap equal to or greater than 15 decibels (dB) at 500Hz, 1000Hz, 2000Hz and 3,000Hz. Conductive or middle ear pathology can cause a difference of greater that 15dB between the air conduction test results and results by bone conduction. Visible evidence of significant cerumen accumulation or a foreign body in the ear canal. Pain or discomfort simply indicates there is something wrong and should be seen by a medical doctor. Infants and children whose medical, physical, or developmental history indicates possible hearing loss: Positive family history of hearing loss. Viral or other non-bacterial transplacental infection. o Defects of ear, nose or throat system; malformed, low-set to absent pinnae; cleft lip or palate. o Birth weight under 1500 grams. 240 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ o Unconjugated bilirubin over 24 mg/100 ml or over infant’s weight in decagrams. o Bacterial meningitis. o Sever asphyxia with arterial flow less than 7.25, coma, seizures or need for continuous assisted ventilation. o Children found positive when tested with pure tone screening. 20.13 Laboratory Tests Providers who conduct Well Child Screens must use their medical judgment when determining the applicability of performing specific laboratory tests and/or analyses. The following are basic laboratory tests that should be performed when a child reaches the required age. 20.13.1 Hematocrit and Hemoglobin Hematocrit or Hemoglobin is completed at the following ages: Newborns (for high risk infants), Two (2) months (for high risk infants), 8-12 months, 18-24 months, Three to four (3-4) years, and 11-12 years. 20.13.2 Blood Lead Level A venous blood lead level determination must be performed on children at 12 and 24 months of age. Children who have a history of pica behavior, an environment suspect of lead exposure, or whose history/physical examination findings are suspicious should have a blood lead level follow-up. Lead poisoning is an elevated venous blood lead level (that is greater than or equal to 10 micrograms per deciliter (ug/dl). If an elevated blood level is discovered, a child should be re-screened every three (3) to four (4) months until lead levels are within normal limits. In addition, a venipuncture blood lead level should be performed annually through at least age six (6). Beginning at six (6) months of age and at each visit thereafter until six (6) years of age providers must discuss with parent(s)/caregiver(s) about childhood lead poisoning interventions and assess the child’s risk for exposure. A verbal interview or written questionnaire, such as the following may identify those children at high risk of lead Ch. 20 Index 241 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ exposure. Blood lead testing should be carried out on those children identified as high risk by this or a similar questionnaire: Does your child live in or regularly visit an old house built before 1950? Is your child’s day care center / preschool / babysitter’s home built before 1978? Does the house have peeling or chipping paint? Does your child live in a house built before 1978 with recent, ongoing, or planned renovation or remodeling (within the last six (6) months)? Do any of your children or their playmates have or had lead poisoning? Does your child frequently come in contact with an adult who works with lead? Examples are construction, welding, pottery, or other trades practiced in your community. Does your child live near a lead smelter, battery recycling plant, or other industry likely to release lead? Do you give your child any home or folk remedies that may contain lead? Does your child live near a heavily traveled major highway where the soil and dust may be contaminated with lead? Does your home’s plumbing have lead pipes or copper with lead solder joints? Ask any additional questions specific to situations existing in the provider’s community. Risk is determined from responses to a verbal or written questionnaire risk assessment. A subsequent verbal risk assessment can change a child’s risk category. Any information suggesting increased lead exposure for previously low risk children must be followed up with a blood lead test. Medicaid will pay for samples to be taken from the home and sent to state laboratory for testing. If answers to all questions are negative, a child is considered low risk for high doses of lead exposure. Practitioners will need to determine whether to perform additional blood lead level test beyond those required at 12 and 24-months of age. If the answers to any questions are positive, a child is considered high risk for high doses of lead exposure. Practitioners are required to perform a venous blood lead level on children determined to be high risk. Tests need to be repeated every three (3) to four (4) months until lead levels are within normal limits. Tests should continue to be completed if the child is still considered high risk. 20.13.3 Tuberculin Screening Tuberculin testing should be completed as indicated on the Well Child Screen Requirements table or more often on clients in high-risk populations (Asian refugees, Indian children, migrant children, etc.), or if historical findings, physical examinations or other risk factors so indicate. Ch. 20 Index 242 Revision 4/1/17 Covered Services –_Health Check_________________________________________________ 20.13.4 Urinalysis Urinalysis using a multiple dipstick method should be completed on all children at two (2) years and 13-15 years. Because of heightened incidence of bacteriuria in girls, they should have additional tests around three (3) years, five (5) years and eight (8) years. Children who have had previous urinary tract infections should be re-screened more frequently. If test results are positive but the history and physical examination are negative, the child should be tested again in seven (7) days. If the results are positive a second (2nd) time or if there are supportive findings in the history and physical examination from the first (1st) positive test, further follow-up is required. If a male child has a urinary tract infection, a referral for further testing should be completed immediately. 20.13.5 Other Other laboratory tests (i.e., chest x-ray, Pap smear, sickle cell testing, etc.) should be completed if medically necessary. 20.14 Immunizations The immunization status of each child should be reviewed at each Well Child Screen. Reviewing the immunization status of a child includes interviewing parents/caretakers, reviewing immunization history/records, and reviewing known high risk factors to which the child may be exposed. Immunizations needed by children at their Well Child Screen should be given on-site, provided there are not existing contradictions. Immunizations are to be given according to the Advisory Committee on Immunization Practices (ACIP). Arrangements should be made with the parents/responsible adult for the completion of immunizations. If immunizations have not been completed at the recommended age, the healthcare professional should set up a schedule to ensure the child becomes current. NOTE: Ch. 20 Index The Recommended Immunization Schedule can http://www.cdc.gov/vaccines/schedules/index.html. 243 be found at Revision 4/1/17 Covered Services –_Health Check_________________________________________________ 20.15 Dental Screen Oral inspections are included in Well Child Screens. Results should be included in the child’s Initial/Interval History. Although an oral inspection is part of Well Child Screens, it does not substitute for an examination through a direct referral to a dentist. A child should be referred to the dentist as follows: When the first tooth erupts and at least yearly thereafter. If an oral inspection reveals cavities, infection, or the child has or is developing a handicapping malocclusion or significant abnormality. NOTE: 20.16 Refer back to Topical Fluoride (20.11, Topical Fluoride Varnish). Speech and Language Screens Speech and language screens identify delays in development of children. Referrals for further speech and hearing evaluations may be appropriate if one (1) or more of the following exists: 20.17 Child is not talking at all by the age of 18 months. Suspected hearing impairment. Child is embarrassed or disturbed by his/her own speech. Voice is monotone, extremely loud, largely inaudible, or of poor quality. There is noticeable hypernasality or lack of nasal resonance. There is undue parental concern. Where speech is not understandable at three (3) years of age, a referral may be appropriate, as the condition may be caused by an unsuspected hearing impairment or a variety of undiagnosed conditions. Discussion and Counseling Parents should have the opportunity to ask questions, to have them answered and to have sufficient time allotted for unhurried discussions. Practitioners should discuss and interpret examination results in accordance with the parents’ level of understanding. NOTE: Ch. 20 Index Interpretation services are available upon request (21.1, Interpreter Services). 244 Revision 4/1/17 Covered Services –_Interpreter Services___________________________________________ Chapter Twenty One – Covered Services – Interpreter Services 21.1 Interpreter Services............................................................................................ 246 21.2 How it Works .................................................................................................... 246 21.3 Covered Services ............................................................................................... 247 21.4 Non-Covered Services ....................................................................................... 247 21.5 Billing Procedures ............................................................................................. 247 21.6 Required Documentation ................................................................................... 247 Ch. 21 Index 245 Revision 4/1/17 Covered Services –_Interpreter Services___________________________________________ 21.1 Interpreter Services Enrolled providers assisting Medicaid clients with oral interpretation or sign language interpretation must adhere to national standards developed by the National Council on Interpreting in Healthcare (NCIHC). These include: Accuracy – To enable other parties to know precisely what each speaker has spoken. Confidentiality – To honor the private and personal nature of the healthcare interaction and maintain trust among all parties. Impartiality – To eliminate the effect of interpreter bias or preference. Role Boundaries – To clarify the scope and limits of the interpreting role, in order to avoid conflicts of interest. Professionalism – To uphold the public’s trust in the interpreting profession. Professional Development – To attain the highest possible level of competence and service. Advocacy – To prevent harm to parties whom the interpreter serves. Procedure Code: T1013 21.2 How it Works A need for interpreter services is determined by a medical appointment. The healthcare provider accesses the Medicaid website or contact Provider Relations for a current list of enrolled interpretation providers (2.1, Quick Reference). The healthcare provider will contact and provide the interpretation service the following information: o Name of client o Client’s Medicaid ID number o Name of referring provider o Time and date service will be required o Location where services will take place (telephonically or in person) o Estimated length of time service will be required The appointment takes place and interpretation services are provided. If any follow-up appointments are needed after the initial appointment, the interpretation services may be arranged at that time. Ch. 21 Index 246 Revision 4/1/17 Covered Services –_Interpreter Services___________________________________________ 21.3 Covered Services The interpretation provider may only bill Medicaid for time spent with the client in conjunction with Medicaid healthcare services delivered by different providers. 21.4 Non-Covered Services Medicaid will not pay for interpreter services in conjunction with the following services: o Inpatient or outpatient hospital services. o Intermediate Care Facilities for persons with Intellectual Disability (ICF-ID). o Nursing facilities. o Ambulance services by public providers. o Psychiatric Residential Treatment Facilities. o Comprehensive inpatient or outpatient rehabilitation facilities. o Other agencies/organizations receiving direct federal funding. Interpreter services provided by family members or by a volunteer, associate or friend. Reimbursement for travel to and from the appointment. Services provided to a client on an ALEN program that are not emergency services. 21.5 Billing Procedures Following are the interpretation services billing procedures or requirements: Interpreters may bill for the same client on the same day more than once if provided in conjunction with Medicaid healthcare services delivered by different providers. The diagnosis code for interpretation services is Z71.0. The procedure code for interpretation services is T1013 and should be billed with the appropriate number of units provided. o One (1) unit = 15 minutes of service. When not providing services in-person the GT modifier must be used. 21.6 Required Documentation Interpretation providers must maintain documentation to support that the service occurred. This should include (at minimum) the client’s name, date of service, times in and out, service provided, and signature of provider. Ch. 21 Index 247 Revision 4/1/17 Covered Services –_Laboratory Services___________________________________________ Chapter Twenty Two – Covered Services – Laboratory Services 22.1 Laboratory Services ........................................................................................... 249 22.2 CLIA Requirements .......................................................................................... 249 22.3 Genetic Testing.................................................................................................. 251 22.3.1 BRCA Testing and Counseling ......................................................................... 251 22.3.2 Counseling ......................................................................................................... 252 22.3.3 Billing Requirements ......................................................................................... 252 Ch. 22 Index 248 Revision 4/1/17 Covered Services –_Laboratory Services___________________________________________ 22.1 Laboratory Services Medicaid covers tests provided by independent (non-hospital) clinical laboratories when the following requirements are met: Services are ordered by physicians, dentists, or other providers licensed within the scope of their practice as defined by law. Services are provided in an office or other similar facility, but not in a hospital outpatient department or clinic. Providers of lab services must be Medicaid certified. Providers of lab services must have a current Clinical Laboratory Improvement Amendments (CLIA) certification number. Providers may bill Medicaid only for those lab services they have performed themselves. Medicaid does not cover reference lab services. Procedure Code Range: 80047-89356 NOTE: 22.2 Non-covered services include routine handling charges, stat fees, postmortem examination and specimen collection fees for throat culture or Pap Smears. CLIA Requirements The type of CLIA certificate required to cover specific codes is listed in the table below. These codes are identified by Center for Medicare and Medicaid Services (CMS) as requiring CLIA certification; however, Medicaid may not cover all of the codes listed. Refer to the fee schedule (2.1, Quick Reference) located on Medicaid website for actual coverage and fees. Content is subject to change at any time, without notice. NOTE: Ch. 22 Index Codes within the below table are NOT Wyoming Medicaid specific. It is the provider’s responsibility to ensure the codes being billed are covered by Wyoming Medicaid. 249 Revision 4/1/17 Covered Services –_Laboratory Services___________________________________________ CLIA CERTIFICATE TYPE REGRISTRATION, COMPLIANCE, OR ACCREDITATION (LABORATORY) (1) PROVIDERPERFORMED MICROSCOPY PROCEDURES (PPMP) (4) WAIVER (2) NO CERTIFICATION NOTE: 80500 86079 86930 80502 86485 86931 88125 88240 88720 89272 88738 89281 Ch. 22 Index ALLOWED TO BILL G0103 G0123 G0124 G0141 G0143 G0144 G0145 G0147 G0148 G0306 G0307 G0328 G0416 G0432 G0433 G0434 G0477 G9143 P3000 17311 17312 17313 17314 17315 78110 78111 78120 78121 78122 78130 78191 78270 78271 78272 80000-89999 (UNLESS OTHERWISE SPECIFIED ELSEWHERE IN THIS TABLE) PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE LABORATORY (CLIA TYPE 1) SECTION AND ALL CODES FOR PPMP (CLIA TYPE 4) SECTION AND WAIVER (CLIA TYPE 2) SECTION AND THE CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) 81000 81001 81015 81020 89055 Q0111 Q0112 Q0113 Q0114 Q0115 89190 G0027 PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE PPMP (CLIA TYPE 4) SECTION AND ALL CODES FOR WAIVER (CLIA TYPE 2) SECTION AND THE CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) 80047 QW 80048 QW 80051 QW 80053 QW 80061 QW 80069 QW 80178 QW 81003 QW 81007 QW 82010 QW 82040 QW 82043 QW 82044 QW 82120 QW 82150 QW 82247 QW 82271 QW 82274 QW 82310 QW 82330 QW 82374 QW 82435 QW 82465 QW 82523 QW 82550 QW 82565 QW 82570 QW 82679 QW 82947 QW 82950 QW 82951 QW 82952 QW 82977 QW 82985 QW 83001 QW 83002 QW 83036 QW 83037 QW 83516 QW 83605 QW 83655 QW 83718 QW 83721 QW 83861 QW 83880 QW 83986 QW 84075 QW 84132 QW 84155 QW 84295 QW 84443 QW 84450 QW 84460 QW 84478 QW 84520 QW 84550 QW 84703 QW 85014 QW 85018 QW 85576 QW 85610 QW 86294 QW 86308 QW 86318 QW 86386 QW 86618 QW 86701 QW 86803 QW 87077 QW 87210 QW 87449 QW 87804 QW 87807 QW 87808 QW 87809 QW 87880 QW 87899 QW 89300 QW 89321 QW G0328 QW G0433 QW G0434 QW G0477 QW 81002 81025 82270 82272 82962 83026 84830 85013 85651 PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE WAIVER (CLIA TYPE 2) SECTION AND ALL CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) PROVIDERS WITHOUT A CLIA MAY BILL ALL CODES EXCLUDED FROM CLIA REQUIREMENTS (SEE BELOW) QW next to a laboratory code signifies that a QW modifier must be used. CODES EXCLUDED FROM CLIA REQUIREMENTS 81050 82075 83013 83014 83987 84061 86486 86490 86510 86580 86891 86910 86932 86945 86950 86960 86965 86985 88304 88305 88312 88313 88241 88311 TC TC TC TC 88741 88749 89049 89220 89240 89251 89290 89354 89398 250 86077 86923 86999 88314 TC 89255 86078 86927 87900 88329 89261 Revision 4/1/17 Covered Services –_Laboratory Services___________________________________________ For updated Medicare CLIA information visit: http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Categorization_of_Tests.html 22.3 Genetic Testing Procedure Codes: 81201-81507; 96040 Prior Authorization is required for all genetic testing codes. Prior authorization documentation must document the following: There is reasonable expectation based on family history, risk factors, or 22.3.1 symptomatology that a genetically inherited condition exists; and Test results will influence decisions concerning disease treatment or prevention; and Genetic testing of children might confirm current symptomatology or predict adult onset diseases and findings might result in medical benefit to the child or as the child reaches adulthood; and Referral is made by a genetic specialist (codes 81223 and 81224) or a specialist in the field of the condition to be tested; and All other methods of testing and diagnosis have met without success to determine the client’s condition such that medically appropriate treatment can be determined and rendered without the genetic testing. (6.14, Prior Authorization). Codes 81420, 81507 - Mother must be documented as high-risk to include: advanced maternal age >35 (at EDC), previous "birth" of embryo/fetus/child with aneuploidy, parent with known balanced translocation, screen positive on standard genetic screening test (FTCS, multiple marker screen of one type or another, etc), ultrasound finding on embryo/fetus consistent with increased risk of aneuploidy BRCA Testing and Counseling The U.S. Preventive Services Task Force (USPSTF) recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for evaluation for BRCA testing (8121181217). Medicaid covers BRCA testing when the following criteria are met: Personal and/or family history of breast cancer, especially if associated with Ch. 22 Index young age of onset; or Multiple tumors; or Triple-negative (i.e., estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2-negative) or medullary histology; or History of ovarian cancer; and 18 years or older; and Pre-test genetic counseling has been prior authorized. 251 Revision 4/1/17 Covered Services –_Laboratory Services___________________________________________ 22.3.2 Counseling Medicaid covers appropriate genetic counseling (96040) when it is provided in conjunction with performance or consideration of medically necessary BRCA testing that meets the criteria listed above. This includes follow-up genetic counseling to discuss the results of these tests. Three (3) 30 minute units (for a total of 90 minutes) are allowed per day. Genetic counseling services may be billed by a physician when the genetic counselor is under physician supervision and is an employee of the physician. Services provided by independent genetic counselors are not a benefit of Wyoming Medicaid. Physician specialties that may bill for BRCA genetic counseling are: 22.3.3 Clinical genetics Family practice OB/GYN Internal medicine Internal medicine, medical oncology General surgery Billing Requirements Prior authorization is required for BRCA pre-test counseling and must be submitted by a physician with a specialty listed above. BRCA testing CPT codes will only be paid with an approved prior authorization for pre-test counseling. Prior authorization requests will need to be submitted to Medical Policy (2.1, Quick Reference) Prior authorization documents should include: o The reason for the test(s); and o Previous lab results; and o How the test results will be utilized; and o How the test results will contribute to improved health outcomes; and o How the test results will alter the client’s treatment management. Providers may contact Medical Policy (2.1, Quick Reference) by telephone for verbal prior authorization. Medical Policy will provide a pending PA number until a formal request is submitted. The formal request must be submitted within 30-days of receiving the pending PA number and must include all documentation required. Ch. 22 Index 252 Revision 4/1/17 Covered Services –_Non-Emergency Medical Transportation_________________________ Chapter Twenty Three – Covered Services – Non-Emergency Medical Transportation 23.1 23.1.1 Non-Emergency Medical Transportation (NEMT) ........................................... 254 Covered services................................................................................................ 254 23.1.1.1 Taxi and non-taxi rides .................................................................................. 254 23.1.1.2 Lodging .......................................................................................................... 254 23.2 Billing Information ............................................................................................ 254 23.2.1 Taxi Rides.......................................................................................................... 254 23.2.2 Non-Taxi Rides ................................................................................................. 255 23.2.3 Lodging ............................................................................................................. 256 Ch. 23 Index 253 Revision 4/1/17 Covered Services –_Non-Emergency Medical Transportation_________________________ 23.1 Non-Emergency Medical Transportation (NEMT) Wyoming Medicaid provides non-emergency medical transportation (NEMT) services to clients who are in need of assistance traveling to and from medical appointments to enrolled providers to obtain covered services. Wyoming Medicaid enrolls taxi providers (344600000X), non-taxi ride providers (347C00000X), and lodging providers (177F00000X) to provide covered services. 23.1.1 Covered services 23.1.1.1 Taxi and non-taxi rides Covered for adults and children Client must call in the ride to the Transportation Call Center (800-595-0011) o Transportation Call Center will verify client is covered for the ride and meets criteria Transportation Call Center will contact Ride Provider once the ride is approved Transportation Call Center will supply client ID for billing purposes to Ride provider 23.1.1.2 Lodging Covered for clients 20 years of age and younger Client must be inpatient or outpatient at a medical facility that is enrolled with Wyoming Medicaid Client must call in the transportation request to the Transportation Call Center and indicate that they are staying with an enrolled lodging provider Client must live more than 400 miles round trip from medical facility o Exceptions may be granted for special circumstances (several appointments over several days; very early appointments; need for direct medical supervision during outpatient recovery; etc. The client must contact Transportation Call Center (800-595-0011) to request exceptions) 23.2 Billing Information 23.2.1 Taxi Rides Procedure codes A0100, S0215 Ch. 23 Index 254 Revision 4/1/17 Covered Services –_Non-Emergency Medical Transportation_________________________ Taxi provider must receive authorization for the taxi ride from the 23.2.2 Transportation Call Center Transportation Call Center will provide client ID and TAC number for billing purposes o The TAC number will be entered as the client’s account number on the claim when billing Bill procedure code A0100 – Base Rate – 1 unit for each one way trip Bill procedure code S0215 – mileage for each mile or part of a mile o Mileage is always rounded up. Example: 5.2 miles would be billed as 6 miles. Mileage without the client on board is not eligible for billing Wait time is not a covered service No show or late clients are not a covered service, however, they should be reported to the Transportation Call Center (800-595-0011) All rides billed are subject to post payment review and as such records should be kept with detail including: o Authorization from Transportation Call Center o Client information o Date and time of pick-up o Pick up address o Destination address o Total mileage o Total charge Non-Taxi Rides Procedure Codes: A0110, A0080 Ride provider must receive authorization for the ride from the Transportation Call Center Transportation Call Center will provide client ID and TAC number for billing purposes o The TAC number will be entered as the client’s account number on the claim when billing Bill procedure code A0110 – Base Rate – 1 unit for each one way trip Bill procedure code A0080 – mileage for each mile or part of a mile above 15 miles NOTE: The first 15 miles are INCLUDED with the base rate and are not billed o Mileage is always rounded up Ch. 23 Index 255 Revision 4/1/17 Covered Services –_Non-Emergency Medical Transportation_________________________ 23.2.3 o Example – A trip of 23.2 miles would be billed with code A0110 as the base rate (1 unit) and A0080 for the mileage (9 units: 23.2 miles 15 base miles = 8.2 miles, round up to 9 miles = 9 units) Mileage without the client on board is not eligible for billing Wait time is not a covered service No show or late clients are not a covered service, however, they should be reported to the Transportation Call Center (800-595-0011) All rides billed are subject to post payment review and as such records should be kept with detail including: o Authorization from Transportation Call Center o Client information o Date and time of pick up o Pick up address o Destination address o Total mileage o Total charge Lodging Procedure Code: A0180 Client must call in transportation to the Transportation Call Center (800-595- Ch. 23 Index 0011) and indicate they are staying with an enrolled lodging provider and provide the TAC number to the lodging provider for billing purposes o The TAC number will be entered as the client’s account number on the claim when billing Client must provide client ID of child to the lodging provider for billing purposes Bill procedure code A0180 for each night of lodging – child client must be inpatient in medical facility or outpatient and staying at lodging provider All lodging claims are subject to post payment review and as such records should be kept with detail including: o Client information o Medical facility client was patient of o Inpatient/outpatient status o Dates of stay o Total nights o Total charge The client’s family will need a copy of receipt/documentation to receive their per diem for the stay 256 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Chapter Twenty Four – Covered Services – Practitioner Services 24.1 Practitioner Services .......................................................................................... 263 24.2 Covered Services ............................................................................................... 263 24.2.1 Abortion............................................................................................................. 263 24.2.1.1 Covered Services ........................................................................................... 263 24.2.1.2 Reimbursement Requirements ....................................................................... 264 24.3 Anesthesia Services ........................................................................................... 264 24.3.1 Covered Services ............................................................................................... 264 24.3.2 Billing Guidelines.............................................................................................. 265 24.3.3 Obstetrical Exceptions ....................................................................................... 266 24.3.4 Modifiers ........................................................................................................... 268 24.3.5 Documentation Requirements ........................................................................... 268 24.4 Dermatology ...................................................................................................... 268 24.4.1 Covered Services ............................................................................................... 269 24.4.2 Benign Lesion Removal and Destruction of Benign or Premalignant Lesions . 269 24.4.3 Covered Services ............................................................................................... 269 24.4.4 Billing Requirements ......................................................................................... 269 24.4.5 Documentation Requirements ........................................................................... 270 24.5 Diabetic Training ............................................................................................... 270 24.5.1 Covered Services ............................................................................................... 271 24.5.2 Billing Requirements ......................................................................................... 271 24.5.3 Documentation .................................................................................................. 271 24.6 Family Planning Services .................................................................................. 271 24.6.1 Covered Services ............................................................................................... 272 24.6.2 Hysterectomies .................................................................................................. 272 24.7 Immunizations ................................................................................................... 272 24.7.1 Billing Procedures: WyVIP Supplied or Private Stock ..................................... 273 24.7.2 Billing Examples ............................................................................................... 277 24.7.3 Other Immunizations ......................................................................................... 279 24.8 Ch. 24 Index Injections ........................................................................................................... 281 257 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.8.1 Belimuab (Benlysta®) Criteria........................................................................... 281 24.8.1.1 Covered Services ........................................................................................... 281 24.8.1.2 Billing Requirements ..................................................................................... 281 24.8.2 Botox®, Dysport® and Myobloc® ...................................................................... 282 24.8.2.1 Covered Services ........................................................................................... 282 24.8.2.2 Billing Requirements ..................................................................................... 282 24.8.3 Synvisc® Injections............................................................................................ 284 24.8.3.1 Covered Services ........................................................................................... 284 24.8.3.2 Limitations ..................................................................................................... 284 24.8.3.3 Billing Requirements ..................................................................................... 285 24.8.4 Tysabri® ............................................................................................................. 285 24.8.4.1 Covered Services ........................................................................................... 285 24.8.4.2 Billing Requirements ..................................................................................... 286 24.8.4.3 Documentation Requirements ....................................................................... 286 24.9 Interpretation Services ....................................................................................... 286 24.10 Laboratory Services ........................................................................................... 287 24.10.1 CLIA Requirements .......................................................................................... 288 24.10.2 Genetic Testing.................................................................................................. 290 24.10.2.1 Covered Services ........................................................................................... 290 24.10.2.2 BRCA Testing and Counseling ..................................................................... 290 24.10.2.3 Billing Requirements ..................................................................................... 291 24.11 24.11.1 Maternity Care ................................................................................................... 291 Billing Requirements ......................................................................................... 291 24.12 Medical Supplies (Disposable) .......................................................................... 295 24.13 Phototherapy for High Bilirubin Levels ............................................................ 295 24.13.1 Billing Requirements ......................................................................................... 296 24.13.2 Phototherapy Maximum Allowable Appeal Process......................................... 296 24.14 Practitioner Visits .............................................................................................. 296 24.14.1 New Client ......................................................................................................... 297 24.14.2 Established Client .............................................................................................. 297 24.14.3 After Hours Services ......................................................................................... 297 24.14.4 Consultation Services ........................................................................................ 298 Ch. 24 Index 258 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.4.1 Billing Requirements ..................................................................................... 298 24.14.4.2 Documentation............................................................................................... 298 24.14.5 Emergency Department Services ...................................................................... 298 24.14.5.1 Covered Services ........................................................................................... 298 24.14.6 Home Visits ....................................................................................................... 299 24.14.6.1 Documentation............................................................................................... 299 24.14.6.2 Limitations ..................................................................................................... 299 24.14.6.3 Billing Requirements ..................................................................................... 300 24.14.7 Critical Care Services ........................................................................................ 301 24.14.8 Prolonged Service.............................................................................................. 301 24.14.9 Practitioner Standby Service ............................................................................. 302 24.14.10 Inpatient Pediatric/Neonatal Critical Care ........................................................ 302 24.14.10.1 Covered Services ........................................................................................... 302 24.14.10.2 Billing Requirements ..................................................................................... 303 24.14.11 Nursing Facilities .............................................................................................. 304 24.14.11.1 Covered Services ........................................................................................... 304 24.14.11.2 Billing Requirements ..................................................................................... 304 24.14.11.3 Nursing Facility Discharge Services ............................................................. 304 24.14.12 Office Visits ...................................................................................................... 305 24.14.12.1 Billing Requirements ..................................................................................... 305 24.14.12.2 Telephone Services ........................................................................................ 305 24.14.12.3 Billing Requirements ..................................................................................... 305 24.15 24.15.1 Preventive Medicine .......................................................................................... 305 Covered Services ............................................................................................... 305 24.16 Public Health Services....................................................................................... 306 24.17 Radiology Services ............................................................................................ 306 24.17.1 Covered Services ............................................................................................... 306 24.17.2 Billing Requirements ......................................................................................... 306 24.17.3 Limitations......................................................................................................... 307 24.18 Screening, Brief Intervention, Referral and Treatment (SBIRT) ...................... 307 24.18.1 Covered Services and Billing Codes ................................................................. 308 24.18.2 Limitations......................................................................................................... 309 Ch. 24 Index 259 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.19 Sterilizations and Hysterectomies ..................................................................... 309 24.19.1 Elective Sterilization ......................................................................................... 309 24.19.2 Hysterectomies .................................................................................................. 310 24.20 Surgical Services ............................................................................................... 311 24.20.1 Surgical Packages, Separate Surgical Procedures and Incidental Surgical Procedures ......................................................................................................... 311 24.20.2 Covered Services ............................................................................................... 312 24.20.3 Limitations......................................................................................................... 312 24.20.4 Billing Requirements ......................................................................................... 312 24.20.5 Assistant Surgeon .............................................................................................. 313 24.20.5.1 Surgical Assistant Service ............................................................................. 313 24.20.5.2 Two (2) Surgeons .......................................................................................... 314 24.20.5.3 Modifiers ....................................................................................................... 314 24.20.6 Cosmetic Services ............................................................................................. 314 24.20.7 Oral and Maxillofacial Surgeons ....................................................................... 315 24.20.7.1 Covered Services ........................................................................................... 315 24.20.7.2 Covered Services ........................................................................................... 315 24.20.7.3 Billing Requirements ..................................................................................... 315 24.20.8 Breast Reconstruction........................................................................................ 316 24.20.8.1 Covered Services ........................................................................................... 316 24.20.8.2 Billing Requirements ..................................................................................... 316 24.20.9 Breast Reduction ............................................................................................... 316 24.20.9.1 Covered Services ........................................................................................... 316 24.20.9.2 Billing Requirements ..................................................................................... 316 24.20.9.3 Documentation Requirements ....................................................................... 317 24.20.10 Cochlear Device, Implantation and Replacement ............................................. 317 24.20.10.1 Covered Services ........................................................................................... 317 24.20.10.2 Billing Requirements ..................................................................................... 317 24.20.10.3 Documentation............................................................................................... 318 24.20.11 Gastric Bypass Surgery ..................................................................................... 319 24.20.12 Lumbar Spinal Surgery ..................................................................................... 319 24.20.12.1 Covered Services ........................................................................................... 319 Ch. 24 Index 260 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.20.12.2 Reimbursement .............................................................................................. 319 24.20.12.3 Scoliosis ......................................................................................................... 320 24.20.13 Panniculectomy/Abdominoplasty ..................................................................... 320 24.20.13.1 Covered Services ........................................................................................... 320 24.20.13.2 Reimbursement .............................................................................................. 320 24.20.14 Pectus Excavatum and Poland’s Syndrome ...................................................... 321 24.20.14.1 Covered Services ........................................................................................... 321 24.20.14.2 Reimbursement .............................................................................................. 321 24.20.15 Ptosis and Blepharoplasty Repair ...................................................................... 322 24.20.15.1 Covered Services ........................................................................................... 322 24.20.15.2 Ptosis (Belpharoptosis) .................................................................................. 322 24.20.15.3 Reimbursement .............................................................................................. 323 24.20.16 Septoplasty and Rhinoplasty ............................................................................. 324 24.20.16.1 Covered Services ........................................................................................... 324 24.20.16.2 Documentation Requirements ....................................................................... 325 24.20.16.3 Reimbursement .............................................................................................. 325 24.20.17 Vagus Nerve Simulation (VNS) for Epilepsy ................................................... 325 24.20.18 Varicose Vein Treatment................................................................................... 326 24.20.18.1 Covered Services ........................................................................................... 326 24.20.18.2 Billing Requirements ..................................................................................... 326 24.21 24.21.1 Transplant Policy ............................................................................................... 327 Outpatient Stem Cell/Bone Marrow .................................................................. 327 24.21.1.1 Non-Covered Services ................................................................................... 327 24.22 24.22.1 Vision Services .................................................................................................. 327 Eye and Office Examinations ............................................................................ 327 24.22.1.1 Covered Services ........................................................................................... 328 24.22.1.2 Non Covered Services ................................................................................... 329 24.22.2 Eyeglasses/Materials ......................................................................................... 329 24.22.2.1 Covered Services ........................................................................................... 329 24.22.2.2 Non Covered Charges .................................................................................... 330 24.22.2.3 Reimbursement .............................................................................................. 330 Ch. 24 Index 261 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.22.3 Contact Lenses .................................................................................................. 331 24.22.3.1 Covered Services ........................................................................................... 331 24.22.3.2 Non-Covered Services ................................................................................... 331 24.22.4 Vision Therapy .................................................................................................. 331 24.22.4.1 Covered Services ........................................................................................... 332 Ch. 24 Index 262 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.1 Practitioner Services Practitioners Include: Physicians (MD/DO). Locum Tenens. Nurse Practitioners. Physician’s Assistants, prior to 7/1/16 can only bill for Medicare crossover claims. Mental Health Providers. Ordering, Rendering and Prescribing Providers. 24.2 Covered Services 24.2.1 Practitioner Visits Pregnant By Abortion Anesthesia Services Dermatology Diabetic Training Family Planning Hysterectomies Imaging Services Immunizations Injections Interpretation Services Laboratory Services Locum Tenens Maternity Care Medical Supplies Choice/Family Planning Waiver Preventive Medicine Psychiatric Services Public Health Services Screening, Brief Intervention, Referral and Treatment (SBIRT) Sterilization Surgical Services Transplant Policy Vision Service Abortion 24.2.1.1 Covered Services Legal (therapeutic) abortions and abortion services will only be reimbursed by Medicaid when a physician certifies in writing that one (1) of the following conditions has been met: The client suffers from a physical injury, or physical illness, including endangering the physical condition caused by or arising from the pregnancy itself, that would place her in danger of death unless an abortion was performed; or Ch. 24 Index 263 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ The pregnancy is the result of sexual assault as defined in Wyoming Statute W.S. 6-2-301, which was reported to a law enforcement agency within five (5) days after the assault or with five days after the time the victim was capable of reporting the assault; or The pregnancy is the result of incest. 24.2.1.2 Reimbursement Requirements The Abortion Certification Form (6.16.3.2, Abortion Certification Form) must accompany all claims from the attending physician, assistant surgeon, anesthesiologist, pathologist and hospital. The attending physician is required to supply all other billing providers with a copy of the consent form. In cases of sexual assault, submission of medical records is not required prior to payment; however, documentation of the circumstances of the case must be maintained in the client’s medical records. Other abortion-related procedures, including spontaneous, missed, incomplete, septic, and hydatiform mole, do not require the certification form; however, all abortion related procedure codes are subject to audit, and all pertinent records must substantiate the medical necessity and be available for review. Pregnancies that terminate in spontaneous abortion/miscarriage in any trimester must bill with the appropriate CPT-4 code and documentation is required in the client’s record. Prenatal visits and additional services may be billed in addition to the abortion code. RU-486 under the same guidelines as the legally induced abortion is covered when administered by a practitioner in the practitioner’s office. NOTE: Reimbursement is available for those induced abortions performed during periods of retroactive eligibility only if the Abortion Certification Form (6.16.3.2, Abortion Certification Form) is completed prior to performing the induced abortion. 24.3 Anesthesia Services Anesthesia is the process of blocking the perception of pain and other sensations. This allows clients to undergo surgery and other procedures without the distress and pain they would otherwise experience. Procedure Code Range: 00100-01999 24.3.1 Covered Services Medicaid covers anesthesia only when administered by a licensed anesthesiologist or a certified registered nurse anesthetist (CRNA) who remains in attendance for the sole Ch. 24 Index 264 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ purpose of rendering general anesthesia in order to afford the client anesthesia care deemed optimal during any procedure. The American Society of Anesthesiologists (ASA) relative value guide is accepted as the basis for coding and definition of anesthesia provided to Medicaid clients. NOTE: 24.3.2 The lower conversion factor of 21 is used in the reimbursement rate for CRNAs. This conversion factor is lower than the conversion factor for anesthesiologists. The most accurate way to verify coverage for a specific service is the review the Medicaid fee schedule on the website or contact Provider Relations (2.1, Quick Reference). Billing Guidelines When billing ASA procedure codes, enter actual minutes for procedures where time is necessary. Fractions of time are always rounded up to the next full number. o For example, enter 65 minutes, rather than one (1) hour five (5) minutes. o For example, nine (9) minutes would be rounded up to 15 minutes. Anesthesia units must be billed in minutes. Do not convert or change time by dividing by 15, the Medicaid’s claims processing system does this automatically. Anesthesia CPT Codes are reimbursed based on the units of the anesthesia procedure and the time units allowed. The total units are multiplied by a conversion factor to determine the allowed amount. Medical supervision is not reimbursed. o For example, claim is billed with 105 units: 105(units billed)/15 = 7 (Anesthesia Units). Add the anesthesia units to the base value (RVU) assigned to the procedure code: 7 + 7= 14. Times that total by the conversion factor for that procedure code: 14 x 27.04 = $378.56 = total paid. Note: The conversion factor and RVU for each anesthesia procedure code can be found on the fee schedule on the Wyoming Medicaid website. Anesthesia time begins when the anesthesiologist starts to prepare for the induction of the anesthesia and ends when the anesthesiologist is no longer in personal attendance. Anesthesia time is the total number of minutes the surgery(ies) is performed. Ch. 24 Index 265 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o For example, preparation of the induction began at 11:00 am and the anesthesiologist was no longer in attendance by 2:15 pm, total minutes would be 195 and is also the number of units to be billed. Providers should bill the appropriate CPT-4 procedure codes for induction/injection of anesthetic agent. When multiple procedures are performed during a single anesthetic administration, Medicaid will pay the anesthesia code representing the most complex procedure reported. The time reported is the combined total for all procedures. Anesthesia is a global service just as the surgical procedure for which it is given. No pre or postoperative services will be recognized for separate payment, including those for: o Pain Management on the same day as surgery. o Routine monitoring is included in the primary anesthesia and not reimbursed separately. For specific information regarding routine monitoring, refer to the current version of the ASA relative value guide. o Laryngoscopy codes 31505, 31515, and 31527 are incidental or included within the anesthesia time. o Any anesthesia substance administered at the time of the procedure for circumcision, cannot be billed separately as this is considered part of the global package. If two (2) anesthesia codes are billed on the same day, (i.e. tubal ligation following vaginal delivery), documentation must be submitted with the claim to support the necessity of these services. NOTE: 24.3.3 Anesthesiologists and CRNA’s are not required to request prior authorization (PA) directly from Medicaid for any anesthesia procedure. Obstetrical Exceptions Procedure code 01967 is a global fee per the fee schedule and should be billed as one (1) unit, not the number of minutes. The Global fee includes: o Establishing and maintaining the anesthesia for the time the client requires it. o If the anesthesia should continue into the next day, use procedure code 01996. Anesthesia for multiple obstetrical procedures may be paid for both procedures in the following circumstances. o Neuraxial analgesia/anesthesia for planned vaginal delivery which becomes a Cesarean delivery. Use procedure code 01967 to begin the procedure and discontinue its use when a C-section is imminent, then begin Ch. 24 Index 266 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ using procedure code 01968 and continue on with straight time (minutes) as for a general surgery. o Neuraxial analgesia/anesthesia for planned vaginal delivery followed by tubal ligation on same or the next day following delivery. Use procedure code 01967 for delivery. Use procedure code 00851 for intraperitoneal lower abdomen, tubal ligation/ transection. NOTE: Ch. 24 Index Medicaid does not allow CPT 01996 on the same day as placement of an epidural catheter. 267 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.3.4 Modifiers When billing for anesthesia, indicate the appropriate physical status modifier. These modifiers indicate various levels of complexity of the anesthesia service provided. If a physical status modifier is billed, additional payment will be added, if appropriate to the claim payment. Physical Status Modifiers Modifier Description Reimbursement P1 A normal healthy client. No change P2 A client with mild systemic disease. No change P3 A client with severe systemic disease. Additional 5% P4 A client with severe systemic disease that is a constant threat to life. Additional 10% P5 A moribund client who is not expected to survive without the operation. Additional 15% P6 A declared brain-dead client whose organs are removed for donor purposes Not covered NOTE: 24.3.5 The use of other optional modifiers may be appropriate. Documentation Requirements Begin and end times must be documented in the anesthesia record and must be legible. Anesthesia time begins when the anesthesiologist begins to prepare the client for anesthesia care in the operating room or an equivalent area and ends when the anesthesiologist is no longer in personal attendance and the client is safely placed under post-anesthesia supervision. If two (2) anesthesia codes are billed on the same day, (i.e. tubal ligation following vaginal deliver), documentation must be submitted with the claim to support the necessity of these services. 24.4 Dermatology Medicaid covers medically necessary services rendered in the treatment of dermatological illnesses. Ch. 24 Index 268 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.4.1 Covered Services Acne surgery due to disfigurement requires prior authorization. (6.14, Prior Authorization) Removal of lesions suspected to be precancerous. Removal of a benign lesion, ganglion cyst, skin tag, keloid, or wart, may be covered when medically necessary. 24.4.2 Benign Lesion Removal and Destruction of Benign or Premalignant Lesions Procedure Code: Procedure Code: Procedure Code Range: Procedure Code Range: 24.4.3 11200 (Removal of Skin Tags 11310 (Removal / Shave Lesion) 11400-11446 (Removal) 17106-17111 (Destruction) Covered Services Benign skin lesions include seborrheic keratosis, sebaceous (epidermoid) cysts, skin tags, milia (keratin-filled cysts), nevi (moles) acquired hyperkeratosis (keratoderma), papillomas, hemangiomas and viral warts. 24.4.4 Billing Requirements Wyoming Medicaid considers removal of benign skin lesions as medically necessary, and not cosmetic, when any of the following is met and is clearly documented in the medical record, operative report or pathology report: The lesion is symptomatic as documented by any of the following: o o o o o o o Ch. 24 Index Intense itching Burning Irritation Pain Tenderness Chronic, recurrent or persistent bleeding. Physical evidence of inflammation (e.g., purulence, oozing, edema, erythema, etc.) The lesion demonstrates a significant change in size or color. The lesion obstructs an orifice or clinically restricts vision. There is clinical uncertainty as to the likely diagnosis, particularly where malignancy is a realistic consideration based on lesional appearance, change in appearance and/or non-response to conventional treatment. The lesion is likely to turn malignant as documented by medical peerreviewed literature or medical textbooks. A prior biopsy suggests the possibility of lesional malignancy. 269 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ The lesion is an anatomical region subjected to recurrent physical trauma that has in fact occurred and objective evidence of such injury or the potential for such injury is documented. Wyoming Medicaid considers destruction of benign or malignant skin lesions as medically necessary, and not cosmetic, when any of the following is met and is clearly documented in the medical record, operative report or pathology report. An over-the-counter (OTC) product has been tried and was ineffective (when applicable) Lesion causes symptoms of such a severity that the patient’s normal bodily functions/activities of daily living are impeded (e.g., palmar or plantar warts) Periocular warts associated with chronic recurrent conjunctivitis thought secondary to lesion virus shedding; Warts showing evidence of spread from one (1) body area to another, particularly in immunosuppressed patients. Lesions are condyloma acuminata or molluscum contagiosum. Cervical dysplasia or pregnancy associated with genital warts. Port wine stains and other hemangiomas when lesions are located on the face and neck. o Only three (3) sessions per PA. o Must include progress notes and photos documenting improvement. NOTE: 24.4.5 Wyoming Medicaid does not consider removal of skin lesions to improve appearance as medically necessary. Removal of certain benign skin lesions that do not pose a threat to health or function are considered cosmetic, and as such, are not medically necessary. In the absence of any of the above indications, removal of seborrheic keratoses, sebaceous cysts, nevi (moles) or skin tags is considered cosmetic. Wart removal can be requested for 3 units at a time. Documentation Requirements One (1) or more of the above conditions, clearly documented in the medical record, operative report or pathology report. 24.5 Diabetic Training Procedure Code Range: G0108-G0109 Physicians, public health nurses, and nurse practitioners managing a client’s diabetic condition are responsible for ordering diabetic training sessions. Certified Diabetic Ch. 24 Index 270 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Educators (CDE) or dieticians employed by a physician, nurse practitioner, or facility may furnish outpatient diabetes self-management training. 24.5.1 Covered Services Individual and group diabetes self-management training sessions are covered. Curriculum will be developed by individual providers and may include, but is not limited to: 24.5.2 Medication education. Dietetic/nutrition counseling. Weight management. Glucometer education. Exercise education. Foot/skin care. Individual plan of care services received by the client. Billing Requirements HCPCS Level II codes, G0108 (individual session) and G0109 (group 24.5.3 session) should be used. Do not bill a separate office visit on the same date of service. For individual services, one (1) unit equals 30 minutes. A maximum of two (2) units applies. For group services, one (1) unit equals 30 minutes. A maximum of five (5) units per individual per training session applies. Billing is to be done under the physician, nurse practitioner or hospital’s provider number. Documentation Documentation should reflect an overview of relative curriculum and any services received by the client. The Diabetic Education Certificate is not required to be submitted with each claim. 24.6 Family Planning Services Family planning services are to assist clients of childbearing age with learning the choices available to them to freely determine the number and spacing of their children. Family planning services include the following: Initial visit Ch. 24 Index 271 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.6.1 Initial physical examination Comprehensive history Laboratory services Medical counseling Annual visits Routine visits Covered Services Sterilization procedures are covered only when all Medicaid guidelines have been met (6.16.1.1, Sterilization Consent Form). Contraceptives Cervical caps Male/female condom Contraceptive injections Creams Diaphragms Foams Insertion/removal of implantable contraceptives (Norplant and Implanon). Insertion/removal of IUDs. Oral contraceptives when prescribed by a physician or nurse practitioner and dispensed a participating pharmacy. Spermicides Sponges NOTE: 24.6.2 Pregnant by Choice/Family Planning Waiver has specific covered and non-covered services. The plan information can be found in Section 25.1. Hysterectomies Procedure Code Range: 58150-58294 Refer to the following sections for information: 6.16.2, Hysterectomy Acknowledgement of Consent. Section 6.16.2.1, Instructions for Completing the Hysterectomy Acknowledgement Consent Form. Section 6.16.2.2, Hysterectomy Consent Form. 24.7 Immunizations Wyoming Vaccinates Important People (WyVIP) Program (formerly VFC). Ch. 24 Index 272 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Providers must enroll with the WyVIP program to receive and distribute WyVIP vaccines. The WyVIP program makes available, at no cost to providers, selected vaccines for eligible children 18 years old and under. Medicaid will therefore pay only for the administration of these vaccines (oral or injection). WyVIP covered vaccines may change from year to year. For more information on the WyVIP program current WyVIP covered vaccines or how to enroll as a WyVIP provider contact the Wyoming Immunization Program at (307)777-7952. 24.7.1 Billing Procedures: WyVIP Supplied or Private Stock Use the following guidelines when submitting claims to Medicaid: Providers must use a WyVIP provided vaccine when available and client Ch. 24 Index appropriate. If the vaccine is supplied by WyVIP, bill the appropriate procedure code and use the SL modifier. Codes 90477-90748 identify the vaccine product only. To report the administration of vaccine/toxoid, the appropriate administration code (see table below) must be reported in addition to the vaccine/toxoid code. Reimbursement will be made for the administration only. When Medicaid is the secondary payer, the provider must submit the claim according to Medicaid guidelines. Bill other potential payers before billing Medicaid. Providers are reminded that use of any vaccine or immunization solely for the purpose of travel is not covered by Medicaid. According to WyVIP policy, providers may not impose a charge for the administration of the vaccine that is higher than the maximum fee established by the Centers for Medicaid and Medicare Services (CMS) regional cap of $21.72 per dose. A previous policy from our office indicated that additional units could be billed for each antigen in the combination vaccination. Separate codes are available for combination vaccines. It is inappropriate to code each component of a combination vaccine separately. Codes 90477-90748 identify the vaccine product only. To receive reimbursement for administration they must be reported in addition to an immunization administration code from the tables below. When a vaccine is privately obtained due to lack of availability through the WyVIP program, it will be reimbursed at 100% of purchase invoice. DO NOT USE the SL modifier in this instance. This policy applies exclusively to situation where the WyVIP Program has issued a notice of vaccine shortage and has specified which vaccines are affected. For vaccines administered to adults over 18 years of age, or for vaccines/toxoids not supplied by WyVIP, report the appropriate CPT code and administration fee. DO NOT USE the SL modifier. Medicaid will reimburse for the vaccine/toxoid and the administration. 273 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ When the vaccine/toxoid product code does not contain the SL modifier, a manufacturers’ invoice must be attached to the claim. The vaccine/toxoid will be reimbursed at 100% of the invoice cost. Exception: o For procedure codes 90656, 90660, 90703, 90707, and 90714, an invoice is only required for those clients age 18 years and younger. Those claims for clients 19 years and older will be reimbursed at a flat rate of $15.00 for these codes. o For procedure code 90658, an invoice is only required for those clients age 18 years and younger. Those claims for clients 19 years and older will be reimbursed at a flat rate of $20.00 for this code. o For procedure code 90715 an invoice is only required for those clients age 18 years and younger. Those claims for clients 19 years and older will be reimbursed at a flat rate of $30.00 for this code. Human Papilloma Virus (HPV) Vaccine o For Codes & 90650 90649 Use CPT-4 code, 90649, for HPV Types 6, 11, 16, and 18 (quadrivalent) Administer intramuscularly as three (3) separate doses. Use CPT code 90650, for HPV Types 16, 18 (bivalent) Administer intramuscularly as three (3) separate doses. If the client turns 19 years of age between the 1st and 2nd doses administration, a VFC supplied vaccine cannot be used to complete the series. Any HPV vaccine administered at age 19 or older must be administered from a provider’s private stock vaccine. If the vaccine is supplied by VFC, bill code 90649 or 90650 with the SL modifier. Also bill the appropriate administration code (see table below). Only the administration code will be reimbursed. If the vaccine is supplied from private stock, bill code 90649 without the SL modifier and attach the manufacturers’ invoice. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at 100% of invoice cost along with the administration code. For Code 90651 o Use CPT-4 code, 90651, for HPV Types 6, 11, 16, 18, 31, 33, 45, 52, and 58 nonvalent (HPV) for females only Administer intramuscularly as three (3) separate doses. If the client turns 19 years of age between the first (1st) and second (2nd) doses administration, a VFC supplied vaccine cannot be used to complete the series. Any HPV vaccine administered at age 19 or older must be administered from a provider’s private stock vaccine. Ch. 24 Index 274 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ The vaccine must be supplied by VFC, bill code 90651 with the SL modifier. Also bill the appropriate administration code (see table below). Only the administration code will be reimbursed. Influenza Vaccine o Medicaid covers influenza vaccines for clients age 6 months and older. If the vaccine is supplied by WyVIP, bill the appropriate procedure code and use the SL modifier. Also bill the appropriate administration code (see table below). Only the administration code will be reimbursed. o For codes 90656 and 90660: If the vaccine is supplied from private stock and the client is 18 years of age or younger, DO NOT USE the SL modifier, and attach a manufacturers’ invoice. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at 100% of invoice cost, along with the administration code. If the vaccine is supplied from private stock, and the client is 19 years of age or older, DO NOT USE the SL modifier. No manufacturers’ invoice is necessary. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at a flat $15.00 rate along with the administration code. For code 90658: o If the vaccine is supplied from private stock and the client is 18 years of age or younger, DO NOT USE the SL modifier, and attach a manufacturers’ invoice. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at 100% of invoice cost, along with the administration code. o If the vaccine is supplied from private stock, and the client is 19 years of age or older, DO NOT USE the SL modifier. No manufacturers’ invoice is necessary. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at a flat $20.00 rate along with the administration code. All other influenza vaccine codes: o If the vaccine is supplied from private stock and the client is of any age, DO NOT USE the SL modifier, and attach a manufactures’ invoice. Also bill the appropriate administration code (see table below). The vaccine will be reimbursed at 100% of invoice cost, along with the administration code. Ch. 24 Index 275 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o When a Medicaid client is a resident of a long-term care facility, the vaccine and administration are included in the nursing home per diem rate, and not paid separately. Pneumococcal Vaccine o Medicaid covers pneumococcal vaccines for where it is medically indicated. o If the vaccine is supplied by WyVIP, bill the appropriate procedure code and use the SL modifier. Also bill the appropriate administration code (see table below). Only the administration code will be reimbursed. o If the vaccine is supplied from private stock and the client is of any age, DO NOT USE the SL modifier, and attach a manufacturers’ invoice. Also bill the appropriate administration at 100% of invoice cost, along with the administration code. o When a Medicaid client is a resident of a long-term care facility, the vaccine and administration are included in the nursing home per diem rate, and not paid separately. NOTE: If a significant separately identifiable Evaluation and Management service (e.g. Office or other outpatient services, preventive medicine services) is performed, the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes. Administration Codes – Physician Provides Face-to-Face Vaccine Counseling CPT Code 90460 90461 Description Immunization administration 0-18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component Each additional vaccine/toxoid component (list separately in addition to code for 1st component) for age 0-18 Administration notes: For vaccines where physician or other qualified health care professional provides counseling, code 90460 will be reported once for each vaccine administered. For any vaccine with multiple components (i.e. DtaP or Tdap), 90461 will be reported for each additional component. If multiple vaccines are administered, “like codes” must be combined onto the same line, using multiple units to avoid denials for duplicates. Medicaid will pay up to the allowable on each unit of 90460, and $0.00 for each unit of 90461. Providers should bill their usual and customary fee for 90460 and $0.00 for 90461. Ch. 24 Index 276 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.7.2 Billing Examples Example 1: Provider administers the HPV vaccine, state supplied with physician counseling: DOS (24A) 01/01/15 01/01/15 Procedure Code (24C) 90649 SL 90460 Charges (24F) $0.00 $21.72 Units (24G) 1 1 DOS (24A) 01/01/15 01/01/15 Procedure Code (24C) 90651 SL 90460 Charges (24F) $0.00 $21.72 Units (24G) 1 1 Example 2: Provider administers Tdap, MMR and Influenza. All are state supplied with physician counseling: DOS (24A) 01/01/15 01/01/15 01/01/15 01/01/15 01/10/15 Procedure Code (24C) 90707 SL 90715 SL 9065 SL 90460 90461 Charges (24F) $0.00 $0.00 $0.00 $65.16 $0.00 Units (24G) 1 1 1 3 4 Explanation of Example 2: Three (3) units of 90460 (one (1) for each vaccine administered to indicate each 1st component) and four (4) units of 90461 (one (1) for each additional component in the Tdap and the MMR vaccine beyond the 1st. Ch. 24 Index 277 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Administration Codes – Face-to-Face Vaccine Counseling Not Provided by Physician CPT Code Description 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one (1) vaccine (single or combination vaccine/toxoid). Do not report in conjunction with 90473. 90472 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). 90473 Immunization administration by intranasal or oral route; one (1) vaccine (single or combination vaccine/toxoid). Do not report with 90471. 90474 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to code for primary procedure (90471 or 90473). For vaccinations where face to face counseling is not provided, 90471 or 90473 is reported for the first vaccine, and 90472 or 90474 (units combined for multiples) for each additional vaccine. Example 4: Provider administers the HPV vaccine, state supplied, without physician counseling: DOS (24A) 01/01/15 01/01/15 Procedure Code (24C) 90649 SL 90471 Charges (24F) $0.00 $14.00 Units (24G) 1 1 DOS (24A) 01/01/15 01/01/15 Procedure Code (24C) 90651 SL 90471 Charges (24F) $0.00 $14.00 Units (24G) 1 1 Example 5: Provider administers Tdap, MMR and Influenza, all state supplied, without physician counseling: Ch. 24 Index 278 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ DOS (24A) 01/01/15 01/01/15 01/01/15 01/01/15 01/01/15 Procedure Code (24C) 90707 SL 90715 SL 90656 SL 90471 90472 Charges (24F) $0.00 $0.00 $0.00 $14.00 $28.00 Units (24G) 1 1 1 1 2 Explanation of Example 5: One (1) unit of 90471 for the first (1st) vaccine, and two (2) units of 90472 for the other two (2) vaccines. NOTE: 24.7.3 WyVIP is not intended for private pay patients. Other Immunizations Other immunizations include, but are not limited to: Synagis o Synagis is used for the prevention of serious lower respiratory tract disease caused by respiratory syncytial virus (RSV) in infants and children under two (2) years of age with chronic lung disease who have required medical therapy for their chronic lung disease within six (6) months before the anticipated RSV season (American Academy of Pediatrics Committee on Infectious Diseases and Committee on Fetus and Newborns). o Wyoming Medicaid will pay for Synagis when ordered by a physician to prevent RSV when the following conditions are met: Chronic Lung Disease: Client is < 24-months of age at start of therapy and has chronic lung disease of prematurity (i.e. bronchopulmonary dysplasia), continues to require medical intervention (chronic corticosteroid or diuretic therapy) or required supplemental oxygen for at least 28 days after birth. Congenital Heart Disease: Client is < 12 months of age at start of therapy and has hemodynamically significant congenital heart disease and one (1) or more of the following: Is receiving medication to control congestive heart failure. Has a diagnosis of moderate to severe pulmonary hypertension. Has a diagnosis of cyanotic heart disease. Prematurity: Client is < 12 months of age at start of RSV season and born at < 28 weeks, six (6) days gestational age. Client is < 12 months of age at start of RSV season and born at 34-weeks, six (6) days or less gestational age Ch. 24 Index 279 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ and has either severe neuromuscular disease or congenital abnormalities, either of which compromise handling of respiratory secretions. Client is < six (6) months of age at start of RSV season and born between 29 weeks, zero (0) days and 35 weeks, six (6) days gestational age. o If Synagis is prescribed outside the normal prescribing guidelines, the physician will need to supply documentation of medical necessity to support prescribing. o Synagis may be provided in a physician’s office or in an outpatient hospital or clinic setting. Because of the short stability once mixed (six (6) hours) and the expense of this medication, every effort should be made to ensure the least amount of waste. Scheduling multiple clients that are in need of this medication within the six (6) hour allotment is suggested. o Synagis may be billed one (1) of two (2) ways: Supplied by a pharmacy and injected at the physician’s office. The physician’s office may bill the appropriate Evaluation and Management code, procedure code 90772 for the injection fee. The physician’s office supplies the medication and gives the injection. The physician submits a claim for the appropriate Evaluation and Management code, procedure code 90378 and appropriated NDC for the Synagis and the 90772 for the injection fee. NOTE: Because of the cost associated with Synagis, only one (1) month’s dose should be billed at a time. Additional Vaccines, Toxoids o CPT-4 codes for vaccines are to be used to bill for the vaccine product itself and are reported in addition to the immunization administration codes (90471, 90472) unless the WyVIP program supplied the vaccine. o Separate codes are available for combination vaccines. It is inappropriate to code each component of a combination vaccine separately. NOTE: Ch. 24 Index The most accurate way to verify coverage for a specific service is to review the Medicaid fee schedule on the website (2.1, Quick Reference). 280 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.8 Injections Reimbursement for J-codes and therapeutic injections include the cost of the administration fee. This cost is already calculated into the fee for each code. NOTE: Therapeutic injections may not be billed with a J-code (6.8, National Drug Code (NDC) Billing Requirement). If multiple drugs are included in a single injection, separate codes may be billed for the drugs, however, the administration fee should be included with only one (1) code. For an accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). Belimuab (Benlysta®) Criteria 24.8.1 Procedure Code: J0490 24.8.1.1 Covered Services Belimumab is covered and considered medically necessary if the below requirements are met. 24.8.1.2 Billing Requirements Prior authorization requirements: Wyoming Medicaid considers Belimumab medically necessary, when all of the following is met and is clearly documented in the medical record, operative report or pathology report: The patient is 18 years of age or older. The patient has a diagnosis of active systemic lupus erythematosus (SLE) disease. The patient has positive autoantibody test results [positive antinuclear antibody (ANA >1:80) and/or anti-dsDNA (>30 IU/mL)]. ONE (1) of the following: o The patient is currently on a standard of care SLE treatment regimen comprised of at least one (1) of the following: corticosteroids, hydroxychloroquine, chloroquine, nonsteroidal anti-inflammatory drugs (NSAIDS), aspirin, and/or immunosuppressives (azathioprine, methotrexate, cyclosporine, oral cyclophosphamide, or mycophenolate). o The patient has a documented intolerance, FDA labeled contraindication, or hypersensitivity to the standard of care drug classes listed above. Ch. 24 Index 281 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Benlysta® (belimumab) PA Criteria Page two (2) of four (4) Current Procedural Terminology copyright American Medical Association. All Rights Reserved. Contains Public Information. The patient does NOT have severe active lupus nephritis [proteinuria >6 g/24hour or equivalent or serum creatinine >2.5 mg/dL OR required hemodialysis or high-dose prednisone >100 mg/day] within the past 90-days. The patient does NOT have severe active central nervous system lupus [e.g. seizures, psychosis, organic brain syndrome, cerebrovascular accident, cerebritis, CNS vasculitis requiring therapeutic intervention] within the past 60-days. The patient has NOT been treated with intravenous cyclophosphamide in the previous six (6) months. The patient is NOT currently using another biologic agent. The patient is NOT currently being treated for a chronic infection. The dose is within the FDA labeled dosage of 10 mg/kg intravenously at two (2) week intervals for the first three (3) doses and at four (4) week intervals thereafter. NOTE: Length of Approval: 12 months. Botox®, Dysport® and Myobloc® 24.8.2 Procedure Code Range: J0585-J0587 24.8.2.1 Covered Services Botulinum toxin type A (e.g., onabotulinumtoxinA [Botox®], or abobotulinumtoxinA [Dysport®]) or B (fimabotulintoxinB [Myobloc®] for the treatment of the following conditions and are considered medically necessary when specific criteria is met. 24.8.2.2 Billing Requirements Prior authorization requirements: Wyoming Medicaid considers Botulinum toxin A (onabotulinumtoxinA [Botox ®] and abobotulinumtoxinA [Dysport®]) appropriate for the treatment of the following conditions and meet medical necessity criteria where it is stated: Strabismus with ALL of the following: 1. Associated with dystonia (impaired or disordered tonicity) 2. ABSENCE of ALL of the following: a. Duane’s syndrome with lateral rectus weakness. b. Restrictive strabismus. c. Strabismus secondary to prior surgical over-recession of the antagonist. Ch. 24 Index 282 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ d. Strabismus deviations more than 50 prism diopters. e. Chronic paralytic strabismus except when used with surgical repair to reduce antagonist contracture. Severe primary hyperhidrosis with ALL of the following: 1. Location is ANY ONE (1) of the following: a. Axillary b. Palmar 2. Treatment is not adequately managed with topical agents 3. The condition causes ANY ONE (1) of the following: a. Functional impairment b. Medical complications Urinary incontinence with ALL of the following: 1. Individual has undergone urodynamic studies with diagnosis of idiopathic detrusor over-activity (IDO). 2. Anticholinergic therapy has failed to provide adequate control. NOTE: Not allowed when an individual has a urinary tract infection, in patients with urinary retention and in patients with post-void residual (PVR) urine volume > 200 mL who are not routinely performing clean intermittent self-catheterization (CIC). Blepharospasm Cranial nerve VII disorders (eg. Hemifacial spasms) Wyoming Medicaid considers Botulinum toxin type A (e.g., onabotulinumtoxinA [Botox®], or abobotulinumtoxinA [Dysport®]) or B (fimabotulintoxinB [Myobloc®] for the treatment of the following conditions are considered medically necessary: Ch. 24 Index Achalasia Cervical Dystonia Chronic anal fissure Hereditary spastic paraplegia Idiopathic torsion dystonia Infantile cerebral palsy, spastic Organic writer’s cramp Orofacial dyskinesia Oromandibular dystonia 283 Spasmodic dysphonia Spasmodic torticollis Spastic hemiplegia Symptomatic torsion dystonia Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Botulinum toxin type A (e.g., onabotulinumtoxinA [Botox®]) for the prevention of migraine headaches is considered medically appropriate if the headaches are chronic with ANY ONE (1) the following criteria met: Initial six (6) month trial for migraine headaches with ALL the following: o o o o Occur 15-days or more per month. Last four (4) hours a day or longer. Experienced for three (3) months or more. Symptoms persist despite adequate trials of a minimum of two (2) agents from different classes used in the treatment of chronic migraines (e.g. Angiotensin-converting enzyme inhibitors/antiotensin II receptor blockers, anti-depressants, anti-epileptics, beta blockers and calcium channel blockers), unless the individual has contraindications to such medications. Continuation of therapy after six (6) month trial for the prevention of migraines with ANY ONE (1) of the following: o Frequency reduced by at least seven (7) days per month. o Duration of headache reduced by at least 100 hours per month. NOTE: Botox® can only be requested one (1) session at a time, with medical necessity provided for each session and only 360 units (three (3) month supply) per limb. Synvisc® Injections 24.8.3 (Hyaluronan, Hyaluronic acid, Sodium Hyaluronate, Hylan polymers) Procedure Code: J7323-J7326 24.8.3.1 Covered Services Hyaluronic Acid Derivatives are injected directly into the knee joint to improve lubrication and reduce the pain associated with osteoarthritis of the knee. Hyaluronic Acid Derivatives are subject to prior authorization as well as step therapy. When prior authorization criteria is met and approval given, step therapy must still be followed. The FDA has not approved intra-articular hyaluronan for joints other than the knee. 24.8.3.2 Limitations Euflexxa® – Is injected into the affected knee, 20 mg once (1) weekly for three (3) weeks, a total of three (3) injections. Synvisc One® – Is injected into the affected knee, 48 mg for one (1) dose only. Synvisc – Is injected into the affected knee, 16 mg once weekly for three (3) weeks, a total of three (3) injections. Ch. 25 Inedx 284 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Hyalgan® – Is injected into the affected knee, 20 mg once (1) weekly for a total of five (5) injections. Orthovisc – Is injected into the affected knee, 30 mg once (1) weekly for three (3) or four (4) injections. Supartz® – Is injected into the affected knee, 25 mg once (1) weekly for a total of five (5) injections. Gel-One® – Is injected into the affected knee, 30 mg, for one (1) dose only. 24.8.3.3 Billing Requirements Prior authorization requirements: Wyoming Medicaid considers Synvisc injections as medically necessary when any of the following is met and is clearly documented in the medical record, operative report or pathology report. The following criteria must be met for approval of coverage: Documented diagnosis of symptomatic osteoarthritis of the knee. Trial of conservative nonpharmacologic treatment, (education, physical therapy, weight loss if appropriate) has not resulted in functional improvement. Medical records documenting these therapies must be submitted. Trial of pharmacotherapy (NSAIDs, COX II Inhibitors, acetaminophen) has not resulted in functional improvement. Pain interferes with functional activities such as ambulation and prolonged standing. Prior therapy with at least one (1) intra-articular corticosteroid injection. Repeat doses of any viscosupplement will be approved only when the following criteria are met: At least six (6) months has elapsed since the previous injection or completion of the prior series of injections. Medical records must document significant improvement in pain and functional capacity of the knee joint. Tysabri® 24.8.4 Procedure Code: J2323 24.8.4.1 Covered Services ® Tysabri is a treatment for MS to delay the accumulation of physical disability and reduce the frequency of clinical exacerbations. It is used as a monotherapy. Tysabri® is recommended for patients who have had an inadequate response to, or are unable to tolerate alternate MS therapies. Ch. 25 Inedx 285 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ NOTE: 24.8.4.2 Tysabri® increases the risk of Progressive Multifocal Leukoencephalopathy (PML), an opportunistic viral infection of the brain that usually leads to death or severe disability. Billing Requirements Prior authorization (PA) requirements: Tysabri® must be prescribed by a neurologist enrolled in the Touch Program. Both the provider administering the Tysabri® and the patient receiving the Tysabri® must be enrolled in the Touch Program. Medicaid will only authorize Tysabri® for clients that have a diagnosis of MS. Length of PA: 12 months For continued PA the neurologist must submit documentation to show improvement or stabilization. Dosage: 300 mg IV infusion every four (4) weeks. Must be billed using the NDC number and the appropriate J-code. NOTE: 24.8.4.3 Medicaid will not cover Tysabri® when used in conjunction with other medications for the treatment of progressive MS. Documentation Requirements Physician’s prescription Complete Prior Authorization Form (6.14, Prior Authorization) Must document an inadequate response to, or inability to tolerate an appropriate trial with at least one (1) of the following interferon agents: o Betaseron o Avonex o Rebif o Copaxone This documentation must include information that states when the drug(s) was started and discontinued, and the reason the drug(s) was discontinued. Documentation must state the date the treating provider and patient were enrolled in the Touch Program, and both must meet all eligibility requirements of that program. As of 11/18/2015, the first infusion can be documented with Initial Notice of Patient Authorization. 24.9 Interpretation Services The Office for Civil Rights (OCR) of the U.S. Department of Health and Human Services (DHHS) enforces Federal laws that prohibit discrimination by healthcare and Ch. 25 Inedx 286 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ human service providers that receive funds from the DHHS. Such laws include Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and Title II of the Americans with Disabilities Act of 1990. In efforts to maintain compliance with this law and ensure that Medicaid clients receive quality medical services, interpretation services should be provided for clients who have Limited English Proficiency (LEP) or are deaf/hard of hearing. The purpose of providing services must be to assist the client in communicating effectively about health and medical issues. Interpretation between English and a foreign language is a covered service for Medicaid clients who have LEP. LEP is defined as “the inability to speak, read, write, or understand the English language at a level that permits an individual to interact effectively with healthcare providers.” Interpretation between sign language or lip reading and spoken language is a covered service for Medicaid clients who are deaf or hard of hearing. Hard of hearing is defined as “limited hearing which prevents an individual from hearing well enough to interact effectively with healthcare providers.” Medicaid providers should arrange this service for their clients by contacting an enrolled interpretation provider prior to the medical appointment. A current list of enrolled interpretation providers and is available on the Medicaid website or upon request from Provider Relations (2.1, Quick Reference). Interpretation services may be provided telephonically (via a language line service) or in person. When coordinating interpreter services for a client it will be necessary to provide the enrolled interpretation provider with the following information: Name of client. Client’s Medicaid ID number. Name of referring provider. Time and date service will be rendered. Location of where service will take place (telephonically or in person). Estimated length of time service will be rendered. 24.10 Laboratory Services Medicaid covers tests provided by independent (non-hospital) clinical laboratories when the following requirements are met: Services are ordered and provided by physicians, dentists, or other providers licensed within the scope of their practice as defined by law. Services are provided in an office or other similar facility, but not in a hospital outpatient department or clinic. Providers of lab services must be Medicaid certified. Ch. 25 Inedx 287 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Providers of lab services must have a current Clinical Laboratory Improvement Amendments (CLIA) certification number. Providers may bill Medicaid only for those lab services they have performed themselves. Medicaid does not cover reference lab services. Procedure Code Range: 80048-89331 NOTE: Non-covered services include routine handling charges, stat fees, postmortem examination and specimen collection fees for throat culture or Pap smears. 24.10.1 CLIA Requirements The type of CLIA certificate required to cover specific codes is listed in the table below. These codes are identified by Center for Medicare and Medicaid Services (CMS) as requiring CLIA certification; however, Medicaid may not cover all of the codes listed. Refer to the fee schedule located on Medicaid website for actual coverage and fees. Content is subject to change at any time, without notice (2.1, Quick Reference). NOTE: Ch. 25 Inedx Codes within the below table are Wyoming Medicaid specific. It is the provider’s responsibility to ensure the codes being billed are covered by Wyoming Medicaid. 288 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ CLIA CERTIFICATE TYPE REGRISTRATION, COMPLIANCE, OR ACCREDITATION (LABORATORY) (1) PROVIDERPERFORMED MICROSCOPY PROCEDURES (PPMP) (4) WAIVER (2) NO CERTIFICATION NOTE: 80500 86079 86930 80502 86485 86931 88125 88240 88720 89272 88738 89281 Ch. 25 Inedx ALLOWED TO BILL G0103 G0123 G0124 G0141 G0143 G0144 G0145 G0147 G0148 G0306 G0307 G0328 G0416 G0432 G0433 G0434 G9143 P3000 17311 17312 17313 17314 17315 78110 78111 78120 78121 78122 78130 78191 78270 78271 78272 80000-89999 (UNLESS OTHERWISE SPECIFIED ELSEWHERE IN THIS TABLE) PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE LABORATORY (CLIA TYPE 1) SECTION AND ALL CODES FOR PPMP (CLIA TYPE 4) SECTION AND WAIVER (CLIA TYPE 2) SECTION AND THE CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) 81000 81001 81015 81020 89055 Q0111 Q0112 Q0113 Q0114 Q0115 89190 G0027 PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE PPMP (CLIA TYPE 4) SECTION AND ALL CODES FOR WAIVER (CLIA TYPE 2) SECTION AND THE CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) 80047 QW 80048 QW 80051 QW 80053 QW 80061 QW 80069 QW 80178 QW 81003 QW 81007 QW 82010 QW 82040 QW 82043 QW 82044 QW 82120 QW 82150 QW 82247 QW 82271 QW 82274 QW 82310 QW 82330 QW 82374 QW 82435 QW 82465 QW 82523 QW 82550 QW 82565 QW 82570 QW 82679 QW 82947 QW 82950 QW 82951 QW 82952 QW 82977 QW 82985 QW 83001 QW 83002 QW 83036 QW 83037 QW 83516 QW 83605 QW 83655 QW 83718 QW 83721 QW 83861 QW 83880 QW 83986 QW 84075 QW 84132 QW 84155 QW 84295 QW 84443 QW 84450 QW 84460 QW 84478 QW 84520 QW 84550 QW 84703 QW 85014 QW 85018 QW 85576 QW 85610 QW 86294 QW 86308 QW 86318 QW 86386 QW 86618 QW 86701 QW 86803 QW 87077 QW 87210 QW 87449 QW 87804 QW 87807 QW 87808 QW 87809 QW 87880 QW 87899 QW 89300 QW 89321 QW G0328 QW G0433 QW G0434 QW G0477 QW 81002 81025 82270 82272 82962 83026 84830 85013 85651 PROVIDERS WITH THIS CLIA TYPE MAY BILL THE CODES WITHIN THE WAIVER (CLIA TYPE 2) SECTION AND ALL CODES EXCLUDED FROM CLIA REQUIREMENTS (REFER TO TABLE BELOW) PROVIDERS WITHOUT A CLIA MAY BILL ALL CODES EXCLUDED FROM CLIA REQUIREMENTS (SEE BELOW) QW next to a laboratory code signifies that a QW modifier must be used. CODES EXCLUDED FROM CLIA REQUIREMENTS 81050 82075 83013 83014 83987 84061 86486 86490 86510 86580 86891 86910 86932 86945 86950 86960 86965 86985 88304 88305 88312 88313 88241 88311 TC TC TC TC 88741 88749 89049 89220 89240 89251 89290 89354 89398 289 86077 86923 86999 88314 TC 89255 86078 86927 87900 88329 89261 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.10.2 Genetic Testing Procedure Codes: 81201-81479; 96040 Prior Authorization is required for all genetic testing codes. Prior authorization documentation must document the following: 24.10.2.1 Covered Services Medicaid covers genetic testing under the following conditions: There is reasonable expectation based on family history, risk factors, or 24.10.2.2 symptomatology that a genetically inherited condition exists; and Test results will influence decisions concerning disease treatment or prevention (in ways that not knowing the test results would not); and Genetic testing of children might confirm current symptomatology or predict adult onset diseases and findings might result in medical benefit to the child or as the child reaches adulthood; and Referral is made by a genetic specialist (codes 81223 and 81224) or a specialist in the field of the condition to be tested; and All other methods of testing and diagnosis have met without success to determine the client’s condition such that medically appropriate treatment can be determined and rendered without the genetic testing. (6.14, Prior Authorization). Codes 81420, 81507 - Mother must be documented as high-risk to include: advanced maternal age >35 (at EDC), previous "birth" of embryo/fetus/child with aneuploidy, parent with known balanced translocation, screen positive on standard genetic screening test (FTCS, multiple marker screen of one type or another, etc), ultrasound finding on embryo/fetus consistent with increased risk of aneuploidy BRCA Testing and Counseling The U.S. Preventive Services Task Force (USPSTF) recommends that women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes be referred for evaluation for BRCA testing (8121181217). Medicaid covers BRCA testing when the following criteria are met: Personal and/or family history of breast cancer, especially if associated with Ch. 25 Inedx young age of onset; or Multiple tumors; or Triple-negative (i.e., estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2-negative) or medullary histology; or History of ovarian cancer; and 18 years or older; and Pre-test genetic counseling has been prior authorized. 290 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.10.2.3 Billing Requirements Enrolled laboratories should bill Medicaid directly for genetic testing, refer to Section 20.3. The following billing procedures must be followed when the physician agrees to act as a third party agent for a non-enrolled laboratory: The following documents must be attached to the claim (6.15, Submitting Attachments for Electronic Claims): The physician’s letter justifying the genetic testing must be attached to the claim. The letter must document the necessity for the genetic testing by meeting the covered service conditions mentioned above. Manufacturer’s invoice (Reimbursement will be invoice plus 15%). No prior authorization is required. NOTE: Post payment claim review will be conducted. 24.11 Maternity Care Maternity services include antepartum, delivery & postpartum care of a pregnant woman, according to guidelines set forth in the current edition of the CPT-4 book. Procedure Code Range: 59000-59898 24.11.1 Billing Requirements Global Care for Routine Obstetric Care According to the AMA, if the global care is provided by the same physician or same physician group, then the appropriate global code must be reported. Global services are to be billed in all cases of a single physician or group providing uncomplicated maternity care. 59400 – Routine OB care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care. 59510 – Routine OB care including antepartum care, cesarean delivery and postpartum. 59610 – Routine OB care including antepartum care, vaginal delivery (with or without episiotomy, and/or forceps) and postpartum care, after previous Csection. 59618 – Routine OB care including antepartum care, C-section and postpartum care, following attempted vaginal delivery after previous Csection. Ch. 25 Inedx 291 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ NOTE: The E&M services (visits) provided within the Global package are included in the antepartum care and are not to be coded separately. The date of service is the date of delivery. The services normally provided in uncomplicated maternity cases include antepartum care, delivery and postpartum care. Antepartum care includes: The initial and subsequent. Physical examination. Recording of the weight, blood pressures and fetal heart tones. Routine chemical urinalysis. Monthly visits up to 28-week’s gestation, biweekly visits to 36 week’s gestation and then weekly visits until delivery. Non-Global Services for Routine Obstetric Care Use the following billing procedures when a patient is seen by a different physician or a different physician group for their antepartum care: If the total antepartum visits with the patient is 1-3, bill the appropriate E&M (Evaluation and Management) code for each visit. Bill only one (1) of the following two (2) antepartum procedure codes (depending on the total number of antepartum visits): o 59425 – Antepartum care only; four (4) to six (6) visits. This code would be used in the case where the patient was only seen for four (4) to six (6) visits and then quit seeing that provider. The provider would not be providing services of delivery or postpartum care. If the provider saw the patient at least four (4) times and no more than six (6) times, this is the correct code the provider would submit. o 59426 – Antepartum care only; seven (7) or more visits. This code would be used for the patient who was seen for seven (7) or more antepartum visits, but the provider did not provide services for delivery or postpartum care. Bill procedure code 59430 for postpartum care only (separate procedure). This code is to be used when the provider did not provide the service of the delivery, but they may have provided the antepartum care. NOTE: Ch. 25 Inedx It is not appropriate to separately report the antepartum, delivery and postpartum care when provided by the same physician or same physician group. However, any other visits or services provided within the antepartum period, other than those listed above, should be coded and reported separately. The date of service is the date of delivery. 292 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Patient has Other Medical Conditions, or a Complicated Pregnancy Use the following billing procedures when the patient has other medical conditions, or a complicated pregnancy: If the provider needs to treat the patient for additional services due to complication of pregnancy, use the proper CPT and ICD codes to reflect the complication. If the provider attempts to bill a separate E&M visit and only code the encounter as a normal pregnancy code, the claim will be denied and considered unbundling of the Global Maternity package. These codes cover attendance at delivery when requested by the provider delivering and initial stabilization of newborn. These codes may be reported in addition to the CPT-4 code for history and examination, but not in addition to the newborn resuscitation code. When billing for a twin delivery, modifier 22 should be added to the delivery code and documentation must accompany the claim. Providers cannot bill two (2) separate delivery codes for the delivery of twins except, when one (1) twin is delivered vaginally and the other by cesarean. Pregnancies that terminate in abortion/miscarriage in any trimester must bill with the appropriate CPT-4 code and documentation is required. Prenatal visits and additional services may be billed in addition to the abortion code. NOTE: When billing for an assistant surgeon at a delivery, use the procedure code for delivery only with an 80 or AS modifier as appropriate. Refer to Section 6.16.1, Sterilization Consent Guidelines for more information if the client is considering sterilization. Elective Inductions and Medical Necessity Induction of labor for medical reasons is appropriate when there may be health risks to the woman or baby if the pregnancy were to continue. Some indications for inducing labor include: High blood pressure caused by the pregnancy. Maternal health problems affecting the pregnancy. Infection in the uterus. Water has broken too early. Fetal growth problems. Documentation, which substantiates that the patient’s condition meets the coverage criteria, must be on file with the provider. Ch. 25 Inedx 293 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ All clams are subject to both pre-payment and post-payment review for medical necessity by Medicaid. Should a review determine that services do not meet all the criteria listed above, payment will be denied or, if the claim has already been paid, action will be taken to recoup the payment for those services. Induction is not a covered service unless it meets the guidelines listed above. Inductions without medical necessity will be subject to post pay reviews and possible recoupment of payments to both the physician and hospital. Obstetrical Ultrasound Procedure Code Range: 76801-76828 Acceptable Modifiers: TC, 22, 26 and 52 Medicaid covers obstetrical ultrasounds during pregnancy when medical necessity is established for one (1) or more of the following conditions: Establish date of conception Discrepancy in size versus fetal age Early diagnosis of ectopic or molar pregnancy Fetal Postmaturity Syndrome Guide for amniocentesis Placental localization associated with abnormal vaginal bleeding (placenta previa) Polyhydramnios or Oligohydramnios Suspected congenital anomaly Suspected multiple births Other conditions related directly to the medical diagnosis or treatment of the mother and/or fetus. NOTE: Maintain all records and/or other documentation that substantiates medical necessity for OB ultrasound services performed for Medicaid clients as documentation may be requested for post-payment review purposes. Medicaid will only pay for two (2) routine ultrasounds per pregnancy. Medicaid will not reimburse obstetrical ultrasounds during pregnancy for any of the following reasons: Determining gender Baby pictures Elective Ch. 25 Inedx 294 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Post-payment review will be conducted on obstetrical ultrasound claims after payment is made to the provider in order to ensure claims meet the Medicaid policies contained in this manual. 24.12 Medical Supplies (Disposable) Procedure Code: 99070 Disposable medical supplies are intended for one (1) time use, not re-use, and specifically related to the active treatment or therapy of the client for a medical illness or physical condition. These supplies have a medical purpose, are consumable and/or expendable and non-durable. This does not include personal care items. They are not to be confused with durable medical supplies/equipment. The following is a partial list: Ace bandage Sling Rib belt Straight Catheter Kit Surgical tray Reimbursement may be allowed for a surgical tray if minor surgery necessitates local anesthesia and other supplies (i.e., gauze, sterile equipment, suturing material) and the surgery is performed in the provider’s office. Examples of procedures requiring a major surgical tray include: Diagnosis biopsies. Wound closures. Removal of cysts or other lesions. Expendable medical supplies such as gauze, dressing, syringes and culture plates, are included in the reimbursement rate for the office visit or test performed. The most accurate way to verify coverage for a specific service/supply is to review the fee schedule on the Medicaid website (2.1, Quick Reference). Supplies and materials, which do not have procedure codes, may be billed with CPT code 99070, which will reimburse billed charge up to $10.00. Claims for more than $10.00 require an attached invoice. These claims will be reimbursed at invoice plus shipping and handling plus 15%. Claims billed with this code will be subject to preand post-payment review (6.15, Submitting Attachments for Electronic Claims). 24.13 Phototherapy for High Bilirubin Levels Procedure Code: E0202 RR Ch. 25 Inedx 295 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Effective with dates of service April 1, 2015 and forward, in order to provide better access to home therapy for newborns with high bilirubin levels, and reduce the number of hospital readmissions for Wyoming Medicaid infants, Wyoming Medicaid will be allowing the below taxonomies to bill the E0202 RR (phototherapy – rental) HCPCS code. All physicians (20s) Nurse Practitioners (363Ls, 367A00000X) Durable Medical Equipment Suppliers (332B00000X) Public Health Nurse’s Offices (251K00000X) 24.13.1 Billing Requirements Procedure code E0202 with the RR (rental only) modifier may be billed using daily units with a maximum of five (5) per lifetime. Practitioner services, such as home or office based visits, home health visits, lab tests, etc., should be billed as appropriate in addition to the rental of the Biliblanket or other phototherapy device. For clinical requirements, refer to the DME Covered Services Manual on the website (2.1, Quick Reference). 24.13.2 Phototherapy Maximum Allowable Appeal Process Wyoming Medicaid encourages providers to submit the initial claim to receive reimbursement for the initial five (5) days. Then, when appealing, submit an Adjustment/Void Request Form (6.18.3.1, Adjustment/Void Request Form) with a corrected claim that has the additional units included along with medical necessity and an appeal letter to the below address. Providers may choose to submit only one (1) claim which includes the additional units along with the medical necessity and the appeal letter to: DME Provider Services Manager 6101 Yellowstone Road, Suite 210 Cheyenne, WY 82002 24.14 Practitioner Visits Procedure Code Range: 99201-99443 Practitioner services are provided in inpatient and outpatient settings and include: Ch. 25 Inedx Consultation services Emergency department services Home visits Hospital services 296 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Nursing facilities Office visits Telephone services NOTE: Practitioner services provided to a client between ages 22 and 64 at an Institution for Mental Disease (IMD) are a non-covered service pursuant to federal Medicaid regulation. This includes Medicare crossover claims for dual eligible clients. An IMD is defined as a hospital, nursing facility, or other institution of 17 beds or more that is primarily engaged in providing diagnosis, treatment, or care of people with mental diseases. 24.14.1 New Client Procedure Code Range: 99201-99205 Medicaid considers a new client to be a client who is new to the practitioner and whose medical and administrative records need to be established. A new client visit should be submitted once per client lifetime per provider. An exception may be allowed when a client has been absent for a period of three (3) years, or more. 24.14.2 Established Client Procedure Code Range: 99211-99215 Medicaid considers an established client to be a client that has been seen by the practitioner and whose medical and administrative records have been established. 24.14.3 After Hours Services Medicaid reimburses physicians and practitioners who see clients in their offices rather than the emergency room, when appropriate. The following codes are only to be used when the client is seen in the physician/practitioner’s office. The following codes may be billed in addition to Evaluation and Management codes. CPT-4 Code 99050 99051 99058 NOTE: Ch. 25 Inedx Physician/Practitioner’s After Hours Billing Codes Description Services provided in the office times other than regularly scheduled office hours, or days when the office is normally closed (e.g. holidays, Saturday, or Sunday) in addition to basic service Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service Do not use these codes for seeing clients in the emergency room. 297 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.4 Consultation Services Procedure Code Range: 99241-99245 Consultation services are when a practitioner’s opinion or advice is sought by another practitioner for further evaluation and/or management of a client for a specific problem. 24.14.4.1 Billing Requirements The request and need for a consultation from the attending practitioner, along with the consultant’s opinion and any service that was ordered or performed, must be documented in the client’s record and communicated to the requesting practitioner. If subsequent to the completion of a consultation, the consultant assumes responsibility for management of all or a portion of the client’s condition(s), the follow-up consultation codes should not be used. If an additional request for an opinion or advice regarding the same or new problem is received from the attending practitioner and documented in the medical record, the office consultation codes may be used again. When billing for a consultation, the NPI of the referring practitioner must be provided on the claim. NOTE: 24.14.4.2 For an accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). Documentation Medicaid requires Documentation of Medical Necessity (3.4, Medical Necessity) to be attached to a claim submitted by the consulting practitioner when a client is seen for an additional consultation within one (1) year of the initial consultation. 24.14.5 Emergency Department Services Procedure Code Range: 99281-99288 Emergency department services provide evaluation, management, treatment and prevention of unexpected illnesses or injuries. Emergency Department is defined as an organized hospital-based facility for the provision of unscheduled, episodic services to clients who present themselves for immediate attention. The facility must be available 24-hours a day. 24.14.5.1 Covered Services Medicaid covers practitioner services performed by: A hospital-based emergency room practitioner; Ch. 25 Inedx 298 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ A private practitioner who furnished emergency room services through arrangement with the hospital; or A private practitioner who is called to the hospital to treat an emergency. The practitioner must document in the client’s medical record if the client’s visit to the emergency room was actually an emergency situation. NOTE: Practitioners are requested to report any potential abuse of emergency room visits to Provider Relations (2.1, Quick Reference). 24.14.6 Home Visits Procedure Code Range: 99341-99350 Home visits are evaluation and management services provided by a practitioner in a private residence. This benefit is not intended to replace those services available in the community through other agency programs, (Best Beginnings, Public Health Nurse, Home Health, etc.) but to offer the attending practitioner another alternative to care for clients. 24.14.6.1 Documentation The following documentation must be included in the client’s medical record: Documentation of practitioner order and treatment plan of care. Documentation of observed medical condition, progress at each visit, any change in treatment, and the client’s response to treatment. Documentation of coordination of care between office and home visit. 24.14.6.2 Limitations Medicaid will reimburse the admitting practitioner for only one (1) initial visit per client for each hospital stay. A comprehensive inpatient hospital visit is not allowed within 30-days of a previous hospital admission with the same diagnosis. Medicaid will not reimburse a comprehensive hospital inpatient exam on the same day as an office visit, nursing home visit or ER visit by the same provider. NOTE: Ch. 25 Inedx For initial inpatient encounters by practitioners other than the admitting practitioner use initial inpatient consultation codes or subsequent hospital care codes. 299 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.6.3 Billing Requirements Initial Hospital Care (99221-99223) – All E&M services (e.g., office visits) Ch. 25 Inedx related to and provided on the same date as an inpatient hospital admission are considered part of that hospital admission. Subsequent Hospital Care (99231-99233) – Subsequent visits are limited to one (1) visit per day unless a Documentation of Medical Necessity is attached and approved by Medicaid. All subsequent hospital care visits are to include the medical record and the results of diagnostic studies and changes in the status since the last assessment by the practitioner (3.4, Medical Necessity). Observation or Inpatient Care Services (99234-99236) – These codes are used when the client is admitted and discharged on the same day. These codes are used to report observation or inpatient hospital care services provided to clients admitted and discharged on the same date of service. It is not required that the client be located in an observation area designated by the hospital as a separate unit. These codes are to be used based on the level of care the client received rather than location. Hospital Discharge Services (99238-99239) – Practitioners may bill for the final day of an inpatient hospital stay when they provide a final examination, discussion of the stay, instructions for continuing care and preparation of discharge records. These codes are only allowed when an initial or subsequent hospital visit is billed on the day of discharge. o To report services provided to a client admitted to the hospital after receiving hospital observation care services on the same date, refer to the hospital inpatient billing instructions. For a client admitted to the hospital on a date subsequent to the date of observation status, the hospital admission is reported using the appropriate initial hospital care codes. Do not report the observation discharge in conjunction with the hospital admission. o All evaluation and management services related to and provided on the same day as an admission to observation status are considered part of that admission. Do not report them separately. This applies regardless of the setting in which the services are provided (e.g., a hospital emergency department, a physician’s office or a nursing facility, etc.). o These codes apply to all practitioner services provided on the same date of client admission to observation status. Do not use these codes for postoperative recovery if the procedure is considered a global procedure. Concurrent Care – Inpatient hospital care provided by two (2) or more practitioners to the same client on the same day. Practitioners who are providing concurrent care should use the subsequent hospital care billing codes. Medicaid will reimburse for these services when all of the following criteria are met: o The practitioners have different specialties or subspecialties; o The condition or injury involves more than one (1) body system; 300 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o The condition or injury is so severe or complex that one (1) practitioner alone cannot handle the client’s care; and o The practitioners are actively co-managing the client’s treatment. 24.14.7 Critical Care Services Procedure Code Range: 99291 Critical care is the treatment of critically ill clients experiencing medical emergencies requiring constant attendance of the practitioner. Critical care is typically provided in a critical care unit. Critical care involves high complexity decision making to assess, manipulate, and support vital system function(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the client’s condition Critical Care services include: The interpretation of cardiac output measurements (93561, 93562) Chest x-rays (71010, 71015, 71020) Blood gases Data stored in computers Gastric intubation (43752, 91105) Temporary transcutaneous pacing (92953) Ventilator management (94002-94003, 94660, 94662) Vascular access procedures (36000, 36410, 36415, 36600) Pulse oximetry (94760, 94762) The critical care codes are used to report the total duration of time spent by a practitioner providing constant attention to a critically ill client. The procedure code 99291 is to report the first 30-74 minutes of critical care should be used only once per day even if the time spent by the physician is not continuous that day. Another procedure code 99292 is used to report each additional 30 minutes (30 minutes = 1 unit) beyond the first 74 minutes. 24.14.8 Prolonged Service Procedure Code Range: face-to-face 99354-99357 and non-face-to-face 9935899359 Prolonged physician services either direct face-to-face or non-face-to-face contact may be billed to Medicaid in addition to other physician’s services. This service is reported when the service is beyond the usual service in either the inpatient or outpatient setting. In addition to other physician service, including E&M services at any level. NOTE: Ch. 25 Inedx Prolonged services that exceed three (3) hours on the same date of service must be documented as medically necessary in the patient’s medical 301 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ record, including the purpose and actual time the physician was detained (3.4, Medical Necessity). 24.14.9 Practitioner Standby Service This procedure code is used to report physician standby service that is requested by another physician and that involves prolonged physician attendance without direct (face-to-face) client contact. The physician may not be providing care or services to other clients during this period. This code is not used if the period of standby ends with the performance of a procedure subject to a “surgical” package by the physician who was on standby. Standby service of less than 30-minutes duration on a given day is not reported separately. Second and subsequent periods of standby beyond the first 30-minutes may be reported only if a full 30-minutes of standby was provided for each unit of service reported. NOTE: This code may not be reported in addition to CPT-4 code 99464 for attendance at delivery. Procedure Code Range: 99360 24.14.10 Inpatient Pediatric/Neonatal Critical Care Procedure Code Range: 99291 24.14.10.1 Covered Services Critical care codes include the following: Ch. 25 Inedx Management Monitoring treatment of the client Parent counseling Direct supervision of the healthcare team in the performance of cognitive and procedural activities Cardiac and respiratory monitoring Continuous and/or frequent vital sign monitoring Heat maintenance Enteral and/or parenteral nutritional adjustments Laboratory service Oxygen 302 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.10.2 Billing Requirements Services start with the date of admission to the NICU and may be reported only once per day, per client. Once the neonate is no longer considered to be critically ill, the appropriate codes for subsequent hospital care should be utilized. The following procedures are also included as part of the global descriptors: Interpretation of chest x-rays. Cardiac output measurements. Pulse oximetry. Blood gases and other information stored in computers. Gastric intubation. Ventilation management. Temporary transcutaneous pacing. Vascular procedures. Chest X-rays. Umbilical venous and arterial catheters. Arterial, central venous or peripheral vessel catheterization. Vascular access procedures. Vascular punctures. Oral or nasogastric tube placement. Endotracheal intubation. Lumbar puncture. Suprapubic bladder aspiration. Bladder catheterization. CPAP management. Surfactant administration. Intravascular fluid administration. Blood transfusion. Monitoring of electronic vital signs. Bedside pulmonary function testing and/or monitoring or interpretation of blood gases or O2 saturation. In addition, specific services are included in the parenthetic note following each NICU code. NOTE: Ch. 25 Inedx The most accurate way to verify coverage for a specific service is to review the CPT-4 book for the appropriate date of service. 303 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.11 Nursing Facilities Procedure Code Range: 99304-99318 A nursing facility is an entity that provides skilled nursing care and rehabilitation services to people with illnesses, injuries or functional disabilities. Most facilities serve the elderly. However, some facilities provide services to younger individuals with special needs such as the developmentally disabled, mentally ill and those requiring drug and alcohol rehabilitation. 24.14.11.1 Covered Services Practitioner services are covered when they are medically necessary and are performed to meet the requirements of continued long-term care. 24.14.11.2 Billing Requirements When a client is admitted to the nursing facility in the course of an encounter in another site of service, such as office or emergency room, all evaluation and management service in conjunction with the admission is considered part of the initial nursing facility care if performed on the same date, and will not be reimbursed separately. Initial client care may be billed only once per long-term care stay unless the client has moved to a different facility and/or changes providers. Evaluation and management codes billed in addition to procedure code 99304 are not reimbursed when performed on the same date as the admission. Hospital discharge or observation discharge services performed on the same date of nursing facility admission or readmission may not be reported separately. Discharge planning codes may not be billed on date of the client’s death. Two (2) subcategories of nursing facility services are recognized. Both subcategories apply to new or established clients; and must be billed by the provider. 24.14.11.3 Nursing Facility Discharge Services Nursing facility discharge day management codes are to be used to report the total duration of time spent by a physician for the final nursing facility discharge of a client. 99315 Nursing Facility discharge day management; 30-minutes or less. 99316 Nursing Facility discharge day management, more than 30-minutes. NOTE: Ch. 25 Inedx For an accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). 304 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.14.12 Office Visits An office visit is considered evaluation and management services provided in a practitioner’s office or in an outpatient or other ambulatory facility. 24.14.12.1 Billing Requirements Office visits for new clients must be billed using CPT-4 codes 99201-99205. Established clients must be billed using CPT-4 codes 99211-99215. Several codes may be used in addition to the above codes when services are provided in a physician or practitioner’s office for emergency care after scheduled routine office hours. Documentation must support the CPT-4 code(s) billed by the practitioner. NOTE: For an accurate listing of codes, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). 24.14.12.2 Telephone Services Procedure Code Range: 99441-99443, limited to physician use only 24.14.12.3 Billing Requirements Telephone evaluation and management service provided by a physician to an established patient, parent, or guardian not originating from a related evaluation and management service provided within the previous seven (7) days nor leading to an evaluation and management service or procedure within the next 24-hours or soonest available appointment. Procedure code 99441: 5 to 10 minutes of medical discussion. Procedure code 99442: 11 to 20 minutes of medical discussion. Procedure code 99443: 21 to 30 minutes of medical discussion. 24.15 Preventive Medicine Procedure Code Range: 99381-99379 24.15.1 Covered Services For specific information on preventive health services for clients under age 21, refer to Section 18.1, Health Check – EPSDT. Preventive health services for clients over 21 are: Cancer screening services. Ch. 25 Inedx 305 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Screening mammographies are limited to a baseline mammography between ages 35 and 39; one (1) screening mammography per year after age 45. All mammograms require a referral. Annual gynecological exam including a Pap smear. One (1) per year following the onset of menses. This should be billed using an extended office visit procedure code. The actual Lab Cytology code is billed by the lab where the test is read and not by the provider who obtains the specimen. 24.16 Public Health Services Public health clinic services are physician and mid-level practitioner services provided in a clinic designated by the Department of Health as a public health clinic. Services must be provided directly by a physician or by a public health nurse under a physician’s immediate supervision (i.e., the physician has seen the client and ordered the service). 24.17 Radiology Services Procedure Code Range: 70010-79999 Radiology services are ordered and provided by practitioners, dentists, or other providers licensed within the scope of their practice as defined by law. Radiology providers must be supervised by a practitioner licensed to practice medicine within the state the services are provided. Imaging providers must meet state facility licensing requirements. Facilities must also meet any additional federal or state requirements that apply to specific tests (e.g., mammography). All facilities providing screening and diagnostic mammography services are required to have a certificate issued by the Federal Food and Drug Administration (FDA). 24.17.1 Covered Services Medicaid provides coverage of medically necessary radiology services, which are directly related to the client’s symptom or diagnosis when provided by independent radiologists, hospitals and practitioners. 24.17.2 Billing Requirements For most radiology services and some other tests, the fee schedules indicate different fees, whether the practitioner provided only the technical component (performed the test), only the professional component (interpreted the test), or both components (also known as the global service). Practitioners must bill only for the services they provide (2.1, Quick Reference). Ch. 25 Inedx 306 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Technical components of imaging services must be performed by appropriately licensed staff (e.g., x-ray technician) operating within the scope of their practice as defined by state law and under the supervision of a practitioner. Multiple procedures performed on the same day must be billed with two (2) units to avoid duplicate denial of service. Modifier 26 TC Description Professional Component Technical Component Reimbursement 30% of allowed fee 70% of allowed fee 24.17.3 Limitations Screening mammographies are limited to a baseline mammography between ages 35 and 39; one (1) screening mammography per year after age 45. All mammograms require a referral by a practitioner. X-rays performed as a screening mechanism or based on standing orders. Separate consultations or procedures unless ordered by the attending practitioner. 24.18 Screening, Brief Intervention, Referral and Treatment (SBIRT) SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance abuse use disorders, as well as those who are at risk of developing these disorders. Primary care centers, hospital emergency rooms, trauma centers and other community settings provide opportunities for early intervention with at-risk substance users before more severe consequences occur. The goal of SBIRT is to make screening for substance abuse a routine part of medical care. Screening is a quick, simple way to identify patients who need further assessment of treatment for substance use disorders. It does not establish definitive information about diagnosis and possible treatment needs. Brief intervention is a single session or multiple sessions of motivational discussion focused on increasing insight and awareness regarding substance use and motivation toward behavior change. Brief intervention can be tailored for variance in population or setting and can be used as a stand-alone treatment for those at-risk as well as a vehicle for engaging those in need of more extensive levels of care. Brief treatment is a distinct level of care and is inherently different from both brief intervention and specialist treatment. Brief treatment is provided to those seeking or already engaged in treatment, who acknowledges problems related to substance use. Brief treatment in relation to traditional or specialist Ch. 25 Inedx 307 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ treatment has increased intensity and is of shorter duration. It consists of a limited number of highly focused and structured clinical sessions with the purpose of eliminating hazardous and/or harmful substance use. Referral to specialized treatment is provided to those identified as needing more extensive treatment than offered by the SBIRT program. The effectiveness of the referral process to specialty treatment is a strong measure of SBIRT success and involves a proactive and collaborative effort between SBIRT providers and those providing specialty treatments to ensure access to the appropriate level of care. A key aspect of SBIRT is the integration and coordination of screening and treatment components into a system of services. This system links a community’s specialized treatment program with a network of early intervention and referral activities that are conducted in medical and social service settings. 24.18.1 Covered Services and Billing Codes Acceptable billing providers for SBIRT include: Physician – All 20X taxonomy types Public Health Clinic – 251K00000X FQHC – 261QF0400X RHC – 261QR1300X Nurse Practitioners – 363L Advanced Practitioner of Psych/Mental Health Nursing – 364SP0808X Certified Nurse Midwives – 367A00000X Nurse Anesthetists – 357500000X Medicaid covers SBIRT services for clients 18 years of age and older. H0049 – Alcohol and/or drug screening, per screening. WY SBIRT Screening Tool – ASSIST – The Mental Health and Substance Abuse Services Division has chosen the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) developed by the World health organization (WHO) The ASSIST screening tool can be accessed through their web site at: http://www.who.int/substance_abuse/activities/assist/en/ H0050 – Alcohol and/or drug services, brief intervention, per 15 minute units – Maximum of four (4) units. NOTE: Ch. 25 Inedx Providers are to bill these codes in addition to the code they will bill for the primary focus of the visit. Screening and brief intervention are not stand alone services, rather they may be part of a medical visit with another problem focus. For example, a patient presents for migraine 308 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ headaches and is given the ASSIST (H0049 – screening). The ASSIST tool indicates the need for brief intervention (H0050 – brief intervention). The physician would bill the most appropriate code for their services related to the initial complaint of migraine headache, in addition to the appropriate SBIRT codes. 24.18.2 Limitations SBIRT will not be covered for clients with services limited to emergency services only. 24.19 Sterilizations and Hysterectomies Procedure Code Range: 58150-58294, 58541-58554, 58600-58720 24.19.1 Elective Sterilization Elective sterilizations are sterilizations completed for the purpose of becoming sterile. Medicaid covers elective sterilizations for men and women when all of the following requirements are met: Clients must complete and sign the Sterilization Consent Form at least 30days, but not more than 180-days, prior to the sterilization procedure. There are no exceptions to the 180-day limitation of the effective time period of the informed consent agreement (e.g., retroactive eligibility). This form is the only form Medicaid accepts for elective sterilizations. If this form is not properly completed, payment will be denied. A complete Sterilization Consent Form must be obtained from the primary physician for all related services (6.16.1, Sterilization Consent Guidelines). The 30-day waiting period may be waived for either of the following reasons: Premature Delivery – The Sterilization Consent Form must be completed and signed by the client at least 30-days prior to the estimated delivery date and at least 72-hours prior to the sterilization. Emergency Abdominal Surgery – The Sterilization Consent Form must be completed and signed by the client at least 72-hours prior to the sterilization procedure. o Clients must be at least 21 years of age when signing the form. o Clients must not have been declared mentally incompetent by a federal, state or local court, unless the client has been declared competent to specifically consent to sterilization. o Clients must not be confined under civil or criminal status in a correctional or rehabilitative facility, including a psychiatric hospital or other correctional facility for the treatment of the mentally ill. Ch. 25 Inedx 309 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Before performing sterilizations, the following requirements must be met: The client must have the opportunity to have questions regarding the sterilization procedure answered to his/her satisfaction. The client must be informed of his/her right to withdraw or withhold consent any time before the sterilization without being subject to retribution or loss of benefits. The client must understand the sterilization procedure being considered is irreversible. The client must be made aware of the discomforts and risks, which may accompany the sterilization procedure being considered. The client must be informed of the benefits associated with the sterilization procedure. The client must know that he/she must have at least 30-days to reconsider his/her decision to be sterilized. An interpreter must be present and sign for those clients who are blind, deaf, or do not understand the language to assure the client has been informed (19.1, Interpreter Services). Informed consent for sterilization may not be obtained under the following circumstances: If the client is in labor or childbirth. If the client is seeking or obtaining an abortion. If the client is under the influence of alcohol or other substances which may affect his/her awareness. 24.19.2 Hysterectomies When sterilization results from a procedure performed to address another medical problem, it is considered a medically necessary sterilization. These procedures include hysterectomies, oophorectomies, salpingectomies and orchiectomies. Every claim submitted to Medicaid for a medically necessary sterilization must be accompanied by one (1) of the following: A complete Hysterectomy Acknowledgement of Consent Form must be obtained from the primary practitioner for all related services. Complete only one (1) section (A, B or C) of this form. When no prior sterility (section B) or life-threatening emergency (section C) exists, the client must sign and date section A of this form (see 42 CFR 441.250 for the federal policy on hysterectomies and sterilizations). The client does not need to sign this form when sections B or C apply. If this form is not properly completed, payment will be denied (6.16.2, Hysterectomy Acknowledgement of Consent). Ch. 25 Inedx 310 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ For clients that become retroactively eligible for Medicaid, the practitioner must verify in writing that the surgery was performed for medical reasons and must document one (1) of the following: o The client was informed prior to the hysterectomy that the operation would render the client permanently incapable of reproducing. o The client was already sterile at the time of the hysterectomy and the reason for prior sterility. NOTE: Pregnant by Choice/Family Planning Waiver has specific covered and non-covered services (25.1, Pregnant by Choice/Family Planning Waiver). 24.20 Surgical Services Procedure Code Range: 10021-69990 Medicaid only covers surgical procedures that are medically necessary. In general, surgical procedures are covered if the condition directly threatens the life of a client, results from trauma demanding immediate treatment, or had the potential for causing irreparable physical damage, the loss or serious impairment of a bodily function, or impairment of normal physical growth and development. These policies follow Medicare guidelines but in cases of discrepancy, the Medicaid policy prevails. 24.20.1 Surgical Packages, Separate Surgical Procedures and Incidental Surgical Procedures Surgical Packages – Procedures that are commonly performed as an integral part of a total service and may not be billed separately. The following services are included in the surgical package in addition to the operation: o Local infiltration, metacarpal/metatarsal/digital block or topical anesthesia o Subsequent to the decision for surgery, one (1) related Evaluation and Management (E&M) encounter on the date immediately prior to or on the date of procedure (including history and physical) o Immediate postoperative care, including dictating operative notes, talking with the family and other physicians o Writing orders o Evaluating the patient in the postanesthesia recovery area o Typical post-operative follow-up care. Separate Surgical Procedures – When a procedure is performed independently of, and is not immediately related to, other services, it may be reported separately under its unique procedure code (e.g., a tonsillectomy and Ch. 25 Inedx 311 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ an adenoidectomy may be billed separately), only if performed on a different day. Incidental Surgical Procedures – Incidental procedures are those procedures performed subsequent to surgery which do not add significantly to the major surgery or are rendered incidental and performed at the same time as the major surgery (e.g., incidental appendectomies, incidental scar excisions). 24.20.2 Covered Services Normal preoperative and postoperative care includes: Pre-Op lab and radiology. Office examinations. Emergency room visits, and hospital visits, including discharge management Routine post-operative care (The number of post-operative days for each procedure is listed within the fee schedules.). 24.20.3 Limitations Consultations and hospital admission are not considered part of the surgical package. NOTE: Services provided to diagnose or treat conditions unrelated to the surgery may be billed with a separate examination code if the primary diagnosis code reflects a different complaint or service. For an accurate listing of codes and the number of postoperative days for each procedure, refer to the fee schedule on the Medicaid website (2.1, Quick Reference). 24.20.4 Billing Requirements All surgical claims for reimbursement for multiple surgical procedures must have an operative report attached (6.15, Submitting Attachments for Electronic Claims). The following methodology applies to reimbursement for surgical procedures (refer to the CPT-4 book for correct use of modifiers): Unusual Procedural Services – When the service(s) provided is greater than that usually required for the listed procedure, it may be identified adding modifier 22 to the usual procedure number. An operative report must accompany the claim for payment. Multiple Procedures – When multiple procedures are performed during the same session, the primary procedure will be paid at 100% of the fee assigned on the fee schedule. The primary procedure must be billed on the first line; the subsequent procedure(s) must be billed on the following line(s) using the 51 modifier, if applicable. Operative reports are required for multiple procedures. Ch. 25 Inedx 312 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Refer to the Medicaid website for the most accurate fee schedule (2.1, Quick Reference). NOTE: The 51 modifier pays at 50% of the customary rate. Bilateral Procedures – When bilateral procedures are performed during the same session, the second procedure will be paid at 75% of the customary rate. If the procedure performed is bilateral, providers should report the procedure with 1 unit of service on line 1 and 1 unit of service on line two (2) using the same procedure code with the 50 modifier. Care should be taken not to designate a procedure as bilateral when the procedure is already identified as a bilateral service in the CPT-4 definition. An example of a bilateral procedure would be a client having a tympanostomy (tubes inserted in the ears) performed on both the left and right ears; it should be billed as follows: Line 01 02 NOTE: Unit 1 1 CPT Code 69433 69433 Modifier 50 Operative reports are required for bilateral procedures. 24.20.5 Assistant Surgeon Assistant surgeon fees are billed with an 80 modifier using the same procedure code billed by the primary surgeon. 24.20.5.1 Surgical Assistant Service Physician assistant, nurse practitioner or clinical nurse specialist service fees Ch. 25 Inedx are billed with an AS modifier using the same procedure code billed by the primary surgeon. Non-physician providers (NPP) should bill with the AS modifier using the same procedure code billed by the primary surgeon. The provider should report the services using his/her own provider identification number with the appropriate site of service. The modifier AS is appended to the CPT-4 code(s) for the procedure(s) the NPP/APP assisted with. Do not use modifier AS if the APP/APP acts as an “extra” pair of hands and not a surgical assistant in place of another surgeon. 313 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.20.5.2 Two (2) Surgeons When two (2) surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62. NOTE: 24.20.5.3 If the co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier AS added, as appropriate. If the procedure code(s) require Prior Authorization, it is the responsibility of the individual practitioner to obtain that authorization. Example; two surgeons perform a surgery and utilize the 62 modifier; both surgeons MUST receive Prior Authorization. Modifiers Medicaid recognizes the following list of modifiers when used in conjunction with CPT-4 surgical procedure codes: Modifier 22 50 51 62 80 AS Description Unusual Procedural Services – An operative report is required. Bilateral Procedures Multiple Procedures Two (2) Surgeons – An operative report is required. Assistant Surgeons Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant at surgery Reimbursement Allowed fee plus 20% 75% of allowed fee 50% of allowed fee 100% of allowed fee 20% of allowed fee 15% of allowed fee 24.20.6 Cosmetic Services Medicaid covers cosmetic services only when it is medically necessary (e.g., restore bodily function or correct a deformity). Before cosmetic services are performed, they must be prior authorized. NOTE: Ch. 25 Inedx Refer to Section 6.14 for Prior Authorization procedures and the fee schedule on the Medicaid website indicates which codes require prior authorization (2.1, Quick Reference). 314 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.20.7 Oral and Maxillofacial Surgeons Procedure Code Range: 21010-21499 Oral and maxillofacial surgery is surgery to correct a wide spectrum of diseases, injuries and defects in the head, neck, face, jaws and the hard and soft tissues of the oral and maxillofacial region. 24.20.7.1 Covered Services Removal of tumor Maxillofacial Prosthetics – Introduction and Removal Repair, Revision and/or Reconstruction Temporomandibular Joint (TMJ) Treatment Procedure Code Range: 40490-42999 24.20.7.2 24.20.7.3 Covered Services Lips (excision and repair) Vestibule of mouth (incision, excision and repair) Tongue and Floor of mouth (incision, excision and repair) Dentoalveolar Structures (incision, excision and other) Palate and Uvula (incision, repair and other) Salivary Gland and Ducts (incision, excision, repair and other) Pharynx, Adenoids, and Tonsils (incision, excision, repair and other) Billing Requirements In order to obtain Medicaid reimbursement for services, the following standards must be observed. The services must be medically necessary and follow generally accepted Ch. 25 Inedx standards of care The service must be a service covered by Medicaid Claims must be made according to Medicaid billing instructions Review the entire surgical section to verify appropriate use of modifiers When billing dental codes refer to the dental manual 315 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ NOTE: The most accurate way to verify coverage for a specific service is to review the CPT-4 book, the CDT book and the Medicaid fee schedule on the website (2.1, Quick Reference). 24.20.8 Breast Reconstruction Procedure Code Range: 19316-19499 24.20.8.1 Covered Services Breast reconstruction following breast cancer treatment 24.20.8.2 Billing Requirements Prior authorization requirements (6.14, Prior Authorization): Wyoming Medicaid covers surgical reconstruction following breast cancer treatment. Additional revisions may only be approved for a repeated constructive surgery based on medical necessity such as the procedures listed below: Secondary surgery includes implant rupture. Wound dehiscence (bursting open). Wound infection. Tattooing of the nipple (included in 19350, 19357-19369 unless the procedure is done after the global setting – then 11920-11921 is appropriate). 24.20.9 Breast Reduction Procedure Code Range: 19318 24.20.9.1 Covered Services Breast reductions are covered and considered medically necessary if the below requirements are met. 24.20.9.2 Billing Requirements Prior authorization requirements (6.14, Prior Authorization): Wyoming Medicaid considers breast reduction surgery as medically necessary, when all of the following is met and is clearly documented in the medical records. Client must be 18 years or older. Amount to be removed from each breast is greater than or equal to 500 grams, or the total to be removed from both breasts exceeds 1000 grams. Preoperative indications for breast surgery must include one (1) or more of the following symptoms: o Breast pain Ch. 25 Inedx 316 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o Shoulder, neck, or back pain o Other persistent neurological symptoms attributable to breast size or weight. o Refractory intertrigo o Significant activities This procedure may be done as a hospital inpatient, hospital outpatient, or in an ASC. 24.20.9.3 Documentation Requirements Documentation must show medical necessity. The patient’s clinical records must be specific and contain the following information: Current clinical notes including history, physical, and preoperative indications for breast surgery. Height and weight. Current bra size. Proposed amount of tissue to be removed from each breast. Duration of time that symptoms have persisted. Conservative methods of treatment tried, such as weight loss or support bras. Photographs of the shoulder to waist, front and lateral. 24.20.10 Cochlear Device, Implantation and Replacement Procedure Code: 69930 24.20.10.1 Covered Services Wyoming Medicaid has instituted the following policy for Cochlear Device Implantation and Replacement. Medicaid reimburses for the implant, external processor and headset. 24.20.10.2 Billing Requirements Prior authorization is required for the procedure, device and replacement device only. (6.14, Prior Authorization) Medicaid clients must meet all the following criteria: There must be a diagnosis of bilateral profound (90db hearing loss) sensorineural hearing impairment that cannot be mitigated by the use of a hearing aid in clients whose auditory cranial nerves can be stimulated. The client must have demonstrated that they cannot benefit from hearing amplification through a trial period of a minimum of six (6) months. There must be freedom from middle ear infection, an accessible cochlear lumen that is structurally suited to implantation, and be free of lesions in the auditory nerve and acoustic areas of the central nervous system. Ch. 25 Inedx 317 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ There must not be a contraindication to having the surgery. The client must have the cognitive ability to use auditory clues. The procedure may only be performed using FDA-approved devices. Evaluation and continued treatment for cochlear transplants must be completed by a Board Certified Specialist. Only one (1) cochlear implant per five (5) year period. An exception may be possible if the implant is proven to no longer be working sufficiently and the manufacture warranty has expired. Initial first year calibration visits are part of the global fee for implementation. Follow up calibration visits will be covered one (1) per year if the implant is authorized or if the client had an existing cochlear device that needs calibration. Additional equipment will be allowed only to replace defective equipment and will not be allowed solely to update equipment. Upgrade equipment can be evaluated once every five (5) years. In addition, the following criteria must be met for adults 21 and older: Must be highly motivated and have appropriate expectations to complete prescribed pre- and post-surgical treatment. In addition the following criteria must be met for children 20 and under: o Implantation will not be considered before the age of 12-months. o Children may be pre-linguistically deafened. o Family members or caregivers must have appropriate expectations, motivation, and resources to assist in completion of treatment and educational services. o Family members must agree to accompany a young child to training sessions and be able to reinforce learning. NOTE: Only the procedure for implantation needs prior authorization; the device does not require a separate prior authorization and must be supplied by the hospital. 24.20.10.3 Documentation The client’s clinical records must be specific and contain the following information: A complete history and physical indicating how the diagnosis of sensorineural hearing impairment was determined. Demonstration of lack of benefit from hearing amplification through a trial period of six (6) months, using appropriate fitted amplification. Documentation of other health conditions. Notation that there has been active family involvement during the diagnosis and treatment sessions for a child who is to have a cochlear transplant. Ch. 25 Inedx 318 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.20.11 Gastric Bypass Surgery Procedure Code Range: 43644, 43770, 43842-43843, 43846-43848 For prior authorization for the above listed procedure codes, please contact WYhealth at (888)545-1710. 24.20.12 Lumbar Spinal Surgery Procedure Code Range: 22207, 22214, 22224, 22533, 22534, 22558, 22612, 22630, 22633, 22800-22808, 22812, 22818, 22840, 22857 and 22862 24.20.12.1 Covered Services Authorization for lumbar spinal surgery has been separated into three (3) general categories: Surgery related to the treatment of sciatica or other nerve root impingements where primary intervention is related to removal of an offending herniated disk. Surgery related to mechanical and anatomical abnormalities for which spinal fusion may be appropriate treatment. Spinal fracture or dislocation, spinal infection (These can be approved with documentation of said fracture/dislocation or infection.). 24.20.12.2 Reimbursement Prior Authorization requirements: In the absence of red flag symptoms or progressive neurological symptoms or signs, members presenting with: Low back pain should undergo conservative therapy, which may include the use of anti-inflammatory medications, aggressive physical therapy with home exercise program, activity modification, physical. Reconditioning or facet or epidural injections. A patient should undergo at least 12-weeks of conservative management for symptomatic spinal stenosis or spondylolisthesis. Patients with only axial low back pain (absence of leg or neurological symptoms) and without demonstrable instability, spondylolisthesis or spinal stenosis should go through conservative therapy for at least six (6) months. Documentation Requirements: Office notes, including history and physical. Detailed documentation of extent and response to conservative therapy (PT, Steroids, Anti-inflammatory Medications, etc.). Radiology reports for MRI’s, CT’s, etc. Ch. 25 Inedx 319 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Complete the prior authorization form with specific procedures with CPT codes. NOTE: The requesting surgeon must personally evaluate the patient on at least two (2) occasions prior within the preceding six (6) months to requesting surgery. 24.20.12.3 Scoliosis The treatment of idiopathic scoliosis medically necessary for any of the following conditions: An increasing curve (greater than 40 degrees) in a growing child; or Scoliosis related pain that is refractory to conservative treatments; or Severe deformity (curve greater than 50 degrees) with trunk asymmetry in children and adolescents; or Thoracic lordosis that cannot be treated conservatively. In the absence of the above-mentioned criteria, idiopathic scoliosis surgery is considered experimental and investigational. Documentation Requirements: Office notes, including history and physical. Detailed documentation of extent and response to conservative therapy (PT, Steroids, Anti-inflammatory Medications, etc.). Radiology reports for MRI’s, CT’s, etc. Complete the prior authorization form with specific procedures with CPT codes. NOTE: The requesting surgeon must personally evaluate the patient on at least two (2) occasions prior within the preceding six (6) months to requesting surgery. 24.20.13 Panniculectomy/Abdominoplasty Procedure Code Range: 15830 and 15847 24.20.13.1 Covered Services Panniculectomies/Abdominoplasties are covered and considered medically necessary if the below requirements are met. 24.20.13.2 Reimbursement Ch. 25 Inedx 320 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Prior Authorization requirements (6.14, Prior Authorization): Wyoming Medicaid considers a Panniculectomy/Abdominoplasty as medically necessary, when all of the following is met and clearly documented in the medical records. Pannus hangs at or below the level of the symphysis pubis. Pannus causes a chronic and persistent skin condition that is refractory to at least six (6) months of medical treatment. In addition to good hygiene practices, treatment should include topical antifungals, topical and/or systemic corticosteroids, and/or local or systemic antibiotics. NOTE: If the procedure is being performed following significant weight loss, in addition to meeting the criteria noted above, there should be evidence that the individual has maintained a stable weight for at least six (6) months. If the weight loss is the result of bariatric surgery, abdominoplasty/panniculectomy should not be performed until at least 18 months after bariatric surgery and only when weight has been stable for at least the most recent six (6) months. Medicaid does not cover abdominoplasty or panniculectomy when performed primarily for ANY of the following indications because it is considered not medically necessary (this list may not be all-inclusive). Treatment of neck or back pain. Improving appearance (i.e. cosmesis). Repairing abdominal wall laxity or diastasis recti. Treating psychological symptomatology or psychosocial complaints. When performed in conjuncture with abdominal or gynecological procedures (e.g., abdominal hernia repair, hysterectomy, obesity surgery) unless criteria for panniculectomy or abdominoplasty are met separately. 24.20.14 Pectus Excavatum and Poland’s Syndrome Procedure Code Range: 21743 24.20.14.1 Covered Services Surgical repair of severe pectus excavatum deformities that cause functional deficit are covered and considered medically necessary when done for medical reasons in clients who meet the criteria listed below. 24.20.14.2 Reimbursement Prior Authorization requirements (6.14, Prior Authorization): Ch. 25 Inedx 321 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Wyoming Medicaid considers a Pectus Excavatum medically necessary, when all of the following is met and clearly documented in the medical records. Medical documentation outlining evidence of complications from the sternal deformity. Complications may include but are not limited to: o Asthma o Atypical chest pain. o Cardiopulmonary impairment documented by respiratory and/or cardiac function tests. o Exercise limitation. Frequent lower respiratory tract infections. An electrocardiogram or echocardiogram is documented in the instance(s) of known heart disease in order to define the relationship between the sternal deformity and cardiac issues; and A CT scan of the test is completed and demonstrates a pectus index of greater than 3.25. The pectus index is calculated by dividing the transverse diameter of the chest by the anterior-posterior diameter. In the absence of the above-mentioned criteria, surgery for pectus excavatum is considered cosmetic. The following interventions are considered experimental and investigational secondary to their effectiveness in the treatment of pectus excavatum: The magnetic min-mover procedure. The vacuum bell. Dynamic Compression Syndrome. Surgery for reconstruction of musculo-skeletal chest wall deformities associated with Poland’s Syndrome are considered medical necessary if syndrome causes functional deficits. 24.20.15 Ptosis and Blepharoplasty Repair Procedure Code Range: 67900-67909 24.20.15.1 Covered Services Surgical repair of ptosis and blepharoplasty that cause functional deficit are covered and considered medically necessary when done for medical reasons in clients who meet the criteria listed below. 24.20.15.2 Ptosis (Belpharoptosis) Repair for laxity of the muscles of the upper eyelid causing functional visual impairment when photographs in straight gaze show the margin reflex difference (distance from the upper lid margin to the reflected corneal light reflex at normal gaze) of 2mm or less. Ch. 25 Inedx 322 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Brow ptosis repair for laxity of the forehead muscles causing functional visual impairment when photographs show the eyebrow below the supra-orbital rim. Eyelid ectropion or entropion repair is considered medically necessary for corneal or conjunctival injury due to ectropion, entropion or trichiasis. Upper eyelid tightening procedures (block resection or tarsal strip with lateral canthal tightening) for member who has refractory corneal or conjunctival inflammation related to exposure from floppy eyelid syndrome. Canthoplasty – Is considered medically necessary as part of a blepharoplasty procedure to correct eyelids that sag so much that they pull down the upper eyelid so that vision is obstructed. NOTE: Visual field testing is not routinely necessary to determine the presence of excess upper eyelid skin, upper eyelid ptosis, or brow ptosis. Each of these three (3) components can be present alone or in any combination, and each may require correction. If both a blepharoplasty and ptosis repair are requested, two (2) photographs may be necessary to demonstrate the need for both procedures: one (1) photograph should show the excess skin above the eye resting on the eyelashes, and a second (2nd) photograph should show persistence of lid lag, with the upper eyelid crossing or slightly above the pupil margin, despite lifting the excess skin above the eye off of the eyelids with tape. If all three (3) procedures (i.e., blepharoplasty, blepharoptosis repair, and brow ptosis repair) are requested, three (3) photographs may be necessary. Congenital Ptosis – Surgical correction of congenital ptosis is medically necessary to allow proper visual development and prevent amblyopia in infants and children with moderate to severe ptosis interfering with vision. Surgery is considered cosmetic if performed for mild ptosis that is only of cosmetic concern. Photographs must be available for review to document that the skin or upper eyelid margin obstructs a portion of the pupil. 24.20.15.3 Reimbursement Prior Authorization requirements (6.14, Prior Authorization): Wyoming Medicaid considers surgical repair for Ptosis and Blepharoplasty when the criteria below are met. Blepharoplasty is considered medically necessary for any of the following indications: To correct prosthesis difficulties in an anophthalmia socket; or To remove excess tissue of the upper eyelid causing functional visual impairment when photographs in straight gaze show eyelid tissue resting on or Ch. 25 Inedx 323 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ pushing down on the eye lashes (Excess tissue beneath the eye rarely obstructs vision, so the lower lid blepharoplasty is rarely covered for this indication); or To repair defects predisposing to corneal or conjunctival irritation: o Corneal exposure o Ectropion (eyelid turned outward) o Entropion (eyelid turned inward) o Pseudotrichiasis (inward misdirection of eyelashes caused by entropion); or To relieve painful symptoms of blepharospasm; or To treat peri-orbital sequelae of thyroid disease and nerve palsy, and periorbital sequelae of other nerve palsy (e.g., the oculomotor nerve). 24.20.16 Septoplasty and Rhinoplasty Procedure Code Range: 30520, 30400-30420, 30430-30450 and 30460-30462 24.20.16.1 Covered Services Septoplasty and Rhinoplasty are covered and considered medically necessary if the below requirements are met. Septoplasty is medically necessary when any of the following clinical criteria is met. o Asymptomatic septal deformity that prevents access to other intranasal areas when such access is required to perform medical necessary surgical procedures (e.g., ethmoidectomy); or o Documented recurrent sinusitis felt to be due to a deviated septum not relieved by appropriate medical and antibiotic therapy; or o Recurrent epistaxis (nosebleeds) related to a septal deformity; or o Septal deviation causing continuous nasal airway obstruction resulting in nasal breathing difficulty not responding to appropriate medical therapy; or o When done in association with cleft palate repair. NOTE: Septoplasty is considered experimental and investigational for all other indications (e.g., allergic rhinitis) because its effectiveness other than the ones listed above has not been established. Rhinoplasty may be considered medically necessary only in the following limited circumstances: o When it is being performed to correct a nasal deformity secondary to congenital cleft lip and/or palate; o Upon individual case review, to correct chronic non-septal nasal airway obstruction from vestibular stenosis (collapsed internal valves) Ch. 25 Inedx 324 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ due to trauma, disease, or congenital defect, when all of the following criteria are met: Prolonged, persistent obstructed nasal breathing; and Physical examination confirming moderate to severe vestibular obstruction; and Airway obstruction will not respond to septoplasty and turbinectomy alone; and Nasal airway obstruction is causing significant symptoms (e.g., chronic rhinosinusitis, difficulty breathing); and Obstructive symptoms persist despite conservative management for three (3) months or greater, which includes, where appropriate, nasal steroids or immunotherapy; and Photographs demonstrate an external nasal deformity; and There is an average 50 % or greater obstruction of nares (e.g., 50 % obstruction of both nares, or 75 % obstruction of one nare and 25 % obstruction of other nare, or 100 % obstruction of one nare), documented by nasal endoscopy, computed tomography (CT) scan or other appropriate imaging modality. 24.20.16.2 Documentation Requirements Documentation of duration and degree of symptoms related to nasal obstruction, such as chronic rhinosinusitis, mouth breathing, etc.; and Documentation of results of conservative management of symptoms; and If there is an external nasal deformity, pre-operative photographs showing the standard 4-way view: anterior-posterior, right and left lateral views, and base of nose (also known as worm's eye view confirming vestibular stenosis; this view is from the bottom of nasal septum pointing upwards); and Relevant history of accidental or surgical trauma, congenital defect, or disease (e.g., Wegener’s granulomatosis, choanal atresia, nasal malignancy, abscess, septal infection with saddle deformity, or congenital deformity); and Results of nasal endoscopy, CT or other appropriate imaging modality documenting degree of nasal obstruction. When rhinoplasty for nasal airway obstruction is performed as an integral part of a medically necessary septoplasty and there is documentation of gross nasal obstruction on the same side as the septal deviation 24.20.16.3 Reimbursement Prior Authorization requirements (6.14, Prior Authorization) 24.20.17 Vagus Nerve Simulation (VNS) for Epilepsy Procedure Code Range: 61850-61888, 64570, 64573 Ch. 25 Inedx 325 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ For prior authorization for the above listed procedure codes, please contact WYhealth at (888)545-1710. 24.20.18 Varicose Vein Treatment Procedure Code Range: 36471- 36479, 37770-37785 24.20.18.1 Covered Services Wyoming Medicaid considers the following procedures medically necessary for treatment of varicose veins: Great saphenous vein or small saphenous vein ligation/division/ stripping, Radiofrequency endovenous occlusion (VNUS procedure) Endovenous laser ablation of the saphenous vein (ELAS) – also known as endovenous laser treatment (EVLT) 24.20.18.2 Billing Requirements Prior authorization requirements (6.14, Prior Authorization): Incompetence at the saphenofemoral junction or saphenopopliteal junction is documented by Doppler or duplex ultrasound scanning, and all of the following criteria are met. Documented reflux duration of 500 milliseconds (ms) or greater in the vein to be treated; and Vein size is 4/5mm or greater in diameter (not valve diameter at junction); and Saphenous varicosities result in any of the following: o Intractable ulceration secondary to venous stasis; or o More than 1 episode of minor hemorrhage from a ruptured superficial varicosity; or a single significant hemorrhage from a ruptured superficial varicosity , especially if transfusion of blood is required; or o Saphenous varicosities result in either of the following and symptoms persist despite a three (3) month trial of conservative management (e.g., analgesics and prescription gradient support compression stockings). NOTE: A trial conservative management is not required for persons with persistent or recurrent varicosities who have undergone prior endovenous catheter ablation procedures or stripping/division/ligation in the same leg because conservative management is unlikely to be successful. o Recurrent superficial thrombophlebitis; or Ch. 25 Inedx 326 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o Severe and persistent pain and swelling interfering with activities of daily living and requiring chronic analgesic medication. Endovenous ablation procedures are considered medically necessary for the treatment of incompetent perforating veins with vein diameter of 3.5mm or great with outward flow duration of 500 milliseconds duration or more, located underneath an active or healed venous. 24.21 Transplant Policy For prior authorization for transplant services, please contact WYhealth at (888)5451710. 24.21.1 Outpatient Stem Cell/Bone Marrow The hospital performing a bone marrow/stem cell transplant on an outpatient basis must bill using procedure code 38240 or 38241 and will be reimbursed at 55% of billed charges. 24.21.1.1 Non-Covered Services Transportation of organs from one (1) facility to another is not covered. 24.22 Vision Services Vision and dispensing services are benefits for client’s ages 0-20. Limited office visits for the treatment of an eye injury or eye disease is available for clients 21 & older. A licensed ophthalmologist, optometrist, or optician, within the Scope of the Practice Act within their respective profession, may provide vision services and dispensing services. Vision services for clients 21 and older are only reimbursable for the treatment of eye disease or eye injury based on the appropriate ICD diagnosis code and client records must support billing of any vision services. Routine eye exams and/or glasses are not a covered benefit for clients 21 and older. NOTE: Wyoming Medicaid will pay the deductible and/or coinsurance due on Medicare crossover claims for post-surgical contact lenses and/or eyeglasses, up to the Medicaid allowable. 24.22.1 Eye and Office Examinations Procedure Code Range: 92002-92014, 99201-99215, 92018-92060, 92081-92226, 92230-92287 Ch. 25 Inedx 327 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ 24.22.1.1 Covered Services For clients under the age of 21 years: Eye exams determine visual acuity and refraction, binocular vision, and eye health. o 92002-92004 - New patient eye exams are a covered benefit for clients who are new to the provider’s practice. o 92012-92014 - Established patient eye exams are a covered benefit once in a 365 day period unless there is medical necessity to support an additional exam. Office visits for the treatment of eye disease or eye injury. o 99201-99215 – May be billed by ophthalmologists for office exams. Documentation: Eye care provider records must reflect medical necessity and include interpretation and report, as appropriate, of the procedure. 92018-92060, 92081-92226, 92230-92287 - Special Ophthalmological Services should be performed only when medically necessary. 99283 requires a prior authorization. For clients 21 years and older: Eye exams to diagnose an eye disease or eye injury. o 92002-92004 - New patient eye exams are a covered benefit for clients who are new to the provider’s practice. o 92012-92014 - Established, patient eye exams are a covered benefit once in a 365 day period unless there is medical necessity to support an additional exam. NOTE: Routine eye exam are not covered for adult clients. Do not bill for routine eye exams for clients 21 years and older. Exam codes may pay, and then upon audit, be taken back as Medicaid abuse recovery. These codes are not limited by diagnosis at this time and should only be billed when medical necessity can be documented to show an eye disease or injury. Office visits as for the treatment of eye disease or eye injury. o 99201-99215 - Ophthalmologists may bill these codes for office exams Documentation: Eye care provider records must reflect medical necessity and include interpretation and report, as appropriate, of the procedure. 92018-92060, 92081-92226, 92230-92287 - Special ophthalmological services should be performed only when medically necessary and will be subject to Ch. 25 Inedx 328 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ post-payment review of the client’s records. 92283 will require a prior authorization. 24.22.1.2 Non Covered Services Exam codes should not be billed for routine eye exams for clients over 21 years old. 24.22.2 Eyeglasses/Materials Procedure Code Range: V2020, V2100-V2499, V2627, V2784 24.22.2.1 Covered Services For Clients under the age of 21 years: One (1) pair of eyeglasses is covered per 365 days V2020 – Standard frames are covered up to $73.49. The provider may not “balance bill” the client for frames that cost more than the allowable amount. o NOTE: Balancing billing example – When the client selects $120 frames and Medicaid allows up to $73.49 then the optometrist should either, mutually agree in writing with the client that the client is responsible for the payment of the frames ($120), or, the provider may bill Medicaid for $73.49 and accept this payment as payment in full for the frames. Covered eye glass lenses: o V2100-V2121 (V2199 requires prior authorization) - Single lenses o V2200-V2221 (V2299 requires prior authorization) – Bifocal lenses o V2300-V2321 (V2399 requires prior authorization) – Trifocal lenses o V2410-V2430 (V2499 requires prior authorization) - High Index Aspheric lens Ch. 25 Inedx Aspheric lenses will only be covered when medically necessary and when they meet the following guidelines listed below: When the power in the highest meridian is - (minus) 6 diopters or more. For example: o A spectacle prescription of -2.00 -4.00 x 180 4.00 + -2.00 = -6.00. This Rx would qualify o A spectacle prescription of -2.00 +5.00 x 180 2.00 + +5.00 = +3.00. This Rx would not qualify for high index aspheric material When the power in the highest meridian is + (plus) 4.00 diopters or more. For example: 329 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ o A spectacle prescription of -2.00 -4.00 x 180 4.00 + -2.00 = -6.00. This Rx would qualify o A spectacle prescription of -2.00 + +5.00 = +3.00. This Rx would not qualify for a high index aspheric material o V2784 – Polycarbonate lens (billed as an add on to a standard C-39 lens) o Lenses must be ordered as pairs. If the lens on one (1) side is aspheric or high index, then the matching lens should also be aspheric or high index, even if it does not meet the threshold. Medicaid will allow one (1) replacement of lenses and frames within the 12 month period if: o There is a change in the prescription for the lenses, use the existing frames if possible. o Eyeglasses are lost or broken beyond repair – This will require documentation stating it was not due to blatant abuse or neglect NOTE: The provider will need to submit an electronic claim and attach necessary documentation of the medical necessity to substantiate why the replacement glasses are needed. The claim will then be review and processed if criteria is met. (6.15 Submitting Attachments) Repair of eyeglasses may be billed upon expiration of the warranty V2623, V2629 (Prosthetic eyes) V2627 (Scleral cover shell) –requires a prior authorization. (6.14 Prior Authorizations) 24.22.2.2 Non Covered Charges Reimbursement for dispensing of frames, frame parts, and/or lenses is not allowed in addition to reimbursement for dispensing of total eyeglasses Clients 21 years of age and older are not covered for eyeglasses 24.22.2.3 Reimbursement Obtain eligibility information from Medicaid prior to placing order for eyewear Verify with client and Provider Relations (1-800-251-1268) if the benefit has been used in the past year Deliver glasses in a reasonable amount of time (typically within one to two weeks) Verify client eligibility for the date of delivery Bill Medicaid on the delivery date of the glasses. The date of delivery must be used as the date of service on a claim. Ch. 25 Inedx 330 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ If the client does not return to receive their glasses, the glasses should be mailed to the client and the mail date used as the date of service. NOTE: If the client is not eligible on the delivery date or does not return for the delivery, the provider may submit an “Order vs Delivery Date Exception Form” for authorization to bill on the order date. (6.14 Order Vs Delivery Date) 24.22.3 Contact Lenses Procedure Code Range: V2500-V2599, 92072 Contact lenses are covered for correction of pathological conditions when useful vision cannot be obtained with regular lenses. 24.22.3.1 Covered Services For Clients under the age of 21 years: V2500-V2599 – Contact lenses require prior authorization (PA) and documentation provided must show medical necessity and state why the client’s vision cannot be corrected with eyeglasses. (6.14 Prior Authorizations) Contact lenses will be reimbursed at the cost of invoice, plus shipping and handling, plus 15% (6.15, Submitting Attachments for Electronic Claims). 92072 – Fitting of contact lens does not require PA, however, should only be billed when PA has been obtained for the lens. 24.22.3.2 Non-Covered Services Contact lenses are not covered for clients 21 and older. 24.22.4 Vision Therapy Procedure Code: 92065, 99070 Vision therapy is a sequence of activities individually prescribed and monitored by the doctor to develop efficient visual skills and processing. It is prescribed after a comprehensive eye examination has been performed and has indicated that vision therapy is an appropriate treatment option. The vision therapy program is based on the results of standardized tests, the needs of the patient, and the patient’s signs and symptoms. Ch. 25 Inedx 331 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ Research has demonstrated vision therapy can be an effective treatment option for individuals under the age of 21 or individuals with Acquired Brain Injury: 24.22.4.1 Ocular motility dysfunctions (eye movement disorders) Non-strabismic binocular disorders (inefficient eye teaming) Strabismus (misalignment of the eyes) Amblyopia (poorly developed vision) Accommodative disorders (focusing problems) Visual information processing disorders, including visual-motor integration and integration with other sensory modalities. Covered Services 92065 – Vision Therapy can be billed for clients under the age of 21 and clients eligible for the Acquired Brain Injury Waiver benefit plan with a qualifying medical diagnosis (See tables below) When administered in the office under the guidance of a practitioner. It requires a number of office visits and depending on the severity of the diagnosed conditions The length of the program typically ranges from several weeks to several months Activities paralleling in-office techniques are typically taught to the patient to be practiced at home to reinforce the developing visual skills Vision therapy visits are capped at 32 per 365-days for treatment of ICD diagnosis o Additional visits or exceptions to these diagnosis codes will be considered on a case by case basis only 99070 - Vision Therapy training aids will be reimbursed at cost of invoice. Invoices must be submitted with documentation of medical necessity to Medial Policy (2.1, Quick Reference) for consideration (6.15, Submitting Attachments for Electronic Claims) Diagnosis Codes for Clients under 21 years old Diagnosis Codes Description Amblyopia H53.031, H53.032, H53.033 Strabismic amblyopia H53.011, H53.012, H53.013 Deprivation amblyopia H53.021, H53.022, H53.023 Refractive amblyopia Strabismus (Concomitant) Ch. 25 Inedx 332 Revision 4/1/17 Covered Services –_Practitioner Services__________________________________________ H50.11, H50.012 Monocular esotropia H50.05 Alternating esotropia H50.11, H50.112 Monocular exotropia H50.15 Alternating exotropia H50.311, H50.312 Intermittent esotropia, monocular H50.32 Intermittent esotropia, alternating H50.331, H50.332 Intermittent exotropia, monocular H50.34 Intermittent exotropia, alternating H50.43 Accommodative component in esotropia Non-strabismic disorder of binocular eye movements H51.11 Convergence insufficiency H51.12 Convergence excess H51.8 Anomalies of divergence Ocular Motor Dysfunction H55.81 Deficiencies of saccadic eye movements H55.89 Deficiencies of smooth pursuit movements Heterophoria H50.51 Esophoria H50.52 Exophoria General Binocular Vision Disorder H53.30 General Binocular Vision Disorder Nystagmus H55.01 Nystagmus Diagnosis Codes for Clients on Acquired Brain Injury Waiver Benefit Plan Diagnosis Codes Description I69.998 Disturbances of vision S06 Family of Codes Late effect injury intracranial injury without mention of skull fracture. Ch. 25 Inedx 333 Revision 4/1/17 Covered Services –_Pregnant by Choice__________________________________________ Chapter Twenty Five – Covered Services – Pregnant by Choice 25.1 Pregnant by Choice/Family Planning Waiver ................................................... 335 25.1.1 Covered Services ............................................................................................... 335 25.1.2 Non-Covered Services ....................................................................................... 335 25.1.3 Eligibility Criteria.............................................................................................. 335 25.1.4 Enrollment Process ............................................................................................ 336 25.2 Ch. 25 Inedx Pregnant by Choice Covered Codes .................................................................. 336 334 Revision 4/1/17 Covered Services –_Pregnant by Choice___________________________________________ 25.1 Pregnant by Choice/Family Planning Waiver Pregnant by Choice provides family planning service to women who have received Medicaid benefits through the Pregnant Women Program. This program extends family planning options to women who would typically lose their Medicaid benefits up to two (2) months postpartum. 25.1.1 Covered Services Initial physical exam and health history, including client education and 25.1.2 counseling related to reproductive health and family planning options, including a pap smear and testing for sexually transmitted diseases. Annual follow up exam for reproductive health/family planning purposes, including a pap smear and testing for sexually transmitted diseases where indicated. Brief and intermediate follow up office visits related to family planning. Necessary family planning/reproductive health-related laboratory procedures and diagnostic tests. Contraceptive management including drugs, devices and supplies. Insertion, implantation or injection of contraceptive drugs or devices. Removal of contraceptive devices. Sterilization services and related laboratory services (when properly completed sterilization consent form has been submitted). Medications required as part of a procedure done for family planning purposes. Services must be provided by an enrolled Medicaid provider. Non-Covered Services Services are limited to approved family planning methods and products approved by the Food and Drug Administration (FDA). Sterilization reversals, infertility services, treatments or abortions. 25.1.3 Eligibility Criteria Ch. 25 Inedx The client must be transitioning from the Pregnant Women Program. She is not eligible for another Medicaid program. Does not have health insurance including Medicare. Is a Wyoming resident. Is a US Citizen. Her age is 19 through 44 years. 335 Revision 4/1/17 Covered Services –_Pregnant by Choice___________________________________________ She is not pregnant. 25.1.4 Enrollment Process The Customer Service Center, Wyoming Department of Health (WDH) must be notified of the pregnancy and birth of the baby. The Customer Service Center, WDH will send a review form and a Pregnant by Choice Questionnaire to women eligible for the Pregnant Women Program while in the two (2) month postpartum period to determine if they are interested in the program. If a mother allows her Medicaid benefits to lapse after the two (2) month postpartum period she will not be eligible for the Pregnant by Choice Program. Eligibility is determined yearly. 25.2 Pregnant by Choice Covered Codes Pregnant By Choice Covered Codes Covered Diagnosis Codes Z30.011 Z30.013, Z30.014, Z30.018, Z30.019 Z30.012 Z30.02 Z30.09 Z30.430 Z30.432 Z30.433 Z30.2 Z30.40 Z30.41 Z30.431 Z30.49 Z30.42, Z30.49 Z30.019, Z30.49 Z30.8 Z32.02 Z32.01 Z11.3 Covered Procedures 99201-99203 Ch. 25 Inedx Diagnosis Code Description General counseling on prescription of oral contraceptives General counseling on initiation of other contraceptive Encounter for emergency contraceptive counseling and prescription Natrl Family pln – avoid preg Other general counseling and advice on contraception Encounter for insertion of intrauterine contraceptive device Encounter for removal of intrauterine contraceptive device Encounter for removal & insertion of IUD Sterilization Contraceptive surveillance, unspecified Surveillance of contraceptive pill Surveillance of intrauterine contraceptive device Surveillance of implantable sub dermal contraceptive Surveillance of other contraceptive method Surveillance of previously prescribed contraceptive methods Other specified contraceptive management Pregnancy examination or test, negative result Pregnancy examination or test, positive result Screening examination for venereal disease Pregnant By Choice Covered Codes Procedure Code Description Office/Outpatient New 336 Revision 4/1/17 Covered Services –_Pregnant by Choice___________________________________________ Pregnant By Choice Covered Codes Covered Diagnosis Codes 99211-99213 11976 11980 11981 11982 11983 57170 58300 58301 58600 58615 58670 58671 90772 96372 80048 80076 81000-81015 81025 82465 82947-82948 84703 85013 85014-85018 86592 86593 86689 86701 86702 86703 87070-87081 87110 87205-87207 87209 87210 87270 87274 87320 87340 Ch. 25 Inedx Diagnosis Code Description Office/Outpatient Established Removal, implantable contraceptive capsules Implant hormone pellet(s) Implant hormone pellet(s) Remove drug implant device Remove/insert drug implant Diaphragm or cervical cap fitting with instructions Insertion of Intrauterine device (IUD) Removal of intrauterine device (IUD) Division of fallopian tube Occlude fallopian tube(s) Laparoscopy tubal cautery Laparoscopy tubal block Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular Basic metabolic panel (calcium, total) Hepatic function panel Urinalysis Urine pregnancy test Cholesterol Glucose Gonadotropin, Chorionic (HCG) Blood count Blood smear exam Syphilis Test Syphilis test non-trep quant HTLV or HIV antibody, confirmatory test (EG, Western Blot) HIV – 1 – Antibody HIV – 2 – Antibody HIV – 1 and HIV – 2, single assay – antibody Culture, bacterial Culture, Chlamydia Smear, primary source Smear complex stain Smear wet mount saline/ink Infectious agent antigen detection Chlamydia Infectious agent antigen detection Herpes Simplex virus type 1 Infectious agent antigen detection multiple step method; Chlamydia Trachomatis Infectious agent antigen detection Hepatitis B surface antigen (HBSAG) 337 Revision 4/1/17 Covered Services –_Pregnant by Choice___________________________________________ Pregnant By Choice Covered Codes Covered Diagnosis Codes 87490 87491 87590 87591 88141-88143 88164-88167 88175 A4266 A4267 A4268 J0696 J1050 J7300 J7301 J7303 J7304 J7307 S4993 T1015 58600 58615 58670 58671 00851 Ch. 25 Inedx Diagnosis Code Description Infectious agent detection by Nucleic Acid (DNA or RNA); Chlamydia Trachomatis, direct probe technique Infectious agent detection by Nucleic Acid (DNA or RNA); Chlamydia Trachomatis, amplified probe technique N.Gonorrhoeae DNA dir prob Infectious agent detection by Nucleic Acid (DNA or RNA); Neisseria Gonorrhoeae, amplified probe technique Cytopathology Cytopathology Cytopath C/V auto fluid redo Diaphragm for contraceptive use Contraceptive supply, condom, male, each Contraceptive supply, condom, female, each Injection, Ceftriaxone sodium, Per 250MG Injection, medroxyprogesterone acetate, contraceptive 150 MG (DepoProvera) Intauterine copper contraceptive Skyla 13.5MG Contraceptive supply, hormone containing vaginal ring, each Contraceptive patch Etonogestrel (Contraceptive) implant system, including implant and supplies Contraceptive pills for birth control Clinic encounter, per visit Ligation or transaction of fallopian tube(s) abdominal or biginal approach, unilateral or bilateral Occlusion of fallopian tube(s) by devices (EG, Bank, Clip, Falope Ring) Vaginal or suprapubic approach Laparoscopy, surgical; with fulguration of oviducts (with or without tran-section) Laparoscopy, surgical; with occlusion of oviducts by device (EG, Bank, Clip or Falope ring) Laparoscopy; tubal ligation/transaction 338 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ Chapter Twenty Six – Covered Services – Therapy Services 26.1 Therapy Services ............................................................................................... 340 26.2 Physical and Occupational Therapy .................................................................. 340 26.2.1 Covered Services ............................................................................................... 340 26.2.2 Limitations......................................................................................................... 341 26.2.3 Documentation .................................................................................................. 341 26.3 Speech Therapy ................................................................................................. 342 26.3.1 Covered Services ............................................................................................... 342 26.3.2 Limitations......................................................................................................... 343 26.3.3 Documentation .................................................................................................. 344 26.3.4 Cap Limits ......................................................................................................... 345 Ch. 26 Index 339 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ 26.1 Therapy Services Physical Therapy – The treatment of physical dysfunction or injury by the use of therapeutic exercise and the application of modalities intended to restore of facilitate normal function or development; also called physiotherapy. Occupational Therapy – Occupational therapy addresses the physical, cognitive, psychosocial, sensory, and other aspects of performance in a variety of contexts to support engagement in everyday life activities that affect health, well-being, and quality of life. Speech Therapy – Services that are necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presences of a communication disability. Restorative (Rehabilitative) Services – Services that help patients keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the client was sick, hurt or suddenly disabled. Maintenance (Habilitative) Services – Services that help patients keep, learn, or improve skills and functioning for daily living. Examples would include therapy for a child who isn’t walking or talking at the expected age. 26.2 Physical and Occupational Therapy 26.2.1 Covered Services Services must be directly and specifically related to an active treatment plan. Independent physical therapy services are only covered in an office or home setting. Physical Therapy & Occupational Therapy – Services may only be provided following physical debilitation due to acute physical trauma or physical illness. All therapy must be physically rehabilitative and provided under the following conditions: o Prescribed during an inpatient stay continuing on an outpatient basis; or as a direct result of outpatient surgery or injury. Manual Therapy Techniques – When a practitioner or physical therapist applies physical therapy and/or rehabilitation techniques to improve the client’s functioning. Occupational Therapy interventions may include: o Evaluations/re-evaluations required to assess individual functional status. o Interventions that develop, improve or restore underlying impairments. Ch. 26 Index 340 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ 26.2.2 Limitations Reimbursement includes all expendable medical supplies normally used at the time therapy services are provided. Additional medical supplies/equipment provided to a client as part of the therapy services for home use will be reimbursed separately through the Medical Supplies Program. Physical and occupational therapy visits are limited to 20 per calendar year 26.2.3 o 20 visits per physical therapy; 20 visits per occupational therapy. (6.9, Cap Limits, 6.9.4 Cap Limit for Therapies Request Form) Visits made more than once daily are generally not considered reasonable. There should be a decreasing frequency of visits as the client improves. Clients age 21 and over are limited to restorative services only. Restorative services are services that assist an individual in regaining or improving skills or strength. Maintenance therapy can be provided for clients 20 and under. Documentation The practitioners and licensed physical therapist’s treatment plan must contain the following: Ch. 26 Index Diagnosis and date of onset of the client’s condition. Client’s rehabilitation potential. Modalities. Frequency. Duration (interpreted as estimated length of time until the client is discharged from physical therapy). Practitioner signature and date of review. Physical therapist’s notes and documented measurable progress and anticipated goals. Initial orders certifying the medical necessity for therapy. Practitioner’s renewal orders (at least every 180-days) certifying the medical necessity of continued therapy and any changes. The ordering practitioner must certify that: o The services are medically necessary. o A well-documented treatment plan is established and reviewed by the practitioner at least every 180-days. o Outpatient physical therapy services are furnished while the client is under their care. Total treatment minutes of the client, including those minutes of active treatment reported under the timed codes and those minutes represented by the untimed codes, must be documented, to include beginning time and ending time for services billed. 341 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ Practitioners and licensed physical therapist’s progress notes must be completed for each date of service and contain the following: Identification of the client on each page of the treatment record; Identification of the type of therapy being documented on each entry (i.e., 97530 vs. 97110); Date and time(s) spent in each therapy session; total treatment minutes of the client, including those minutes of active treatment reported under timed codes and those minutes represented by the untimed codes, must be documented, to include beginning time and ending time for each service billed; Description of therapy activities, client reaction to treatment and progress being made to stated goals/outcomes; Full signature or counter signature of the licensed therapist, professional title and date that entry was made and the signature of the therapy assistant and date the entry was made. Licensed therapist must sign progress notes of assistants within 30-days. 26.3 Speech Therapy Speech (pathology) therapy services are those services necessary for the diagnosis and treatment of speech and language disorders, which result in communication disabilities and for the diagnosis and treatment of swallowing disorders (dysphagia), regardless of the presences of a communication disability. 26.3.1 Covered Services Speech therapy services provided to Medicaid clients must be restorative for clients 21 and over. Maintenance therapy can be provided for clients 20 and under. The client must have a diagnosis of a speech disorder resulting from injury, trauma or a medically based illness. There must be an expectation that the client’s condition will improve significantly. To be considered medically necessary, the services must meet all the following conditions: Be considered under standards of medical practice to be a specific and effective treatment for the client’s condition. Be of such a level of complexity and sophistication, or the condition of the client must be such that the services required can be performed safely and effectively only by a qualified therapist or under a therapist’s supervision. Be provided with the expectation that the client’s condition will improve significantly. The amount, frequency and duration of services must be reasonable. Ch. 26 Index 342 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ In order for speech therapy services to be covered, the services must be related directly to an active written treatment plan established by a practitioner and must be medically necessary to the treatment of the client’s illness or injury. In addition to the above criteria, restorative therapy criteria will also include the following: If an individual’s expected restoration potential would be insignificant in relation to the extent and duration of services required to achieve such potential, the speech therapy services would not be considered medically necessary If at any point during the treatment it is determined that services provided are not significantly improving the client’s condition, they may be considered not medically necessary and discontinued. 26.3.2 Limitations The following conditions do not meet the medical necessity guidelines, and therefore will not be covered: Clients age 21 and over are limited to restorative services only. Restorative services are services that assist an individual in regaining or improving skills or strength. Maintenance therapy can be provided for clients age 20 and under. Self-correcting disorders (e.g., natural dysfluency or articulation errors that are self-correcting). Services that are primarily educational in nature and encountered in school settings (e.g., psychosocial speech delay, behavioral problems, attention disorders, conceptual handicap, mental retardation, developmental delays, stammering and stuttering). Services that are not medically necessary. Treatment of dialect and accent reduction. Treatment whose purpose is vocationally or recreationally based. Diagnosis or treatment in a school-bases setting. Maintenance therapy consists of drills, techniques, and exercises that preserve the present level of function so as to prevent regression of the function and begins when therapeutic goals of treatment have been achieved and no further functional progress is apparent or expected. NOTE: Ch. 26 Index In cases where the client receives both occupational and speech therapy, treatments should not be duplicated and separate treatment plans and goals should be provided. 343 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ 26.3.3 Documentation The practitioners and licensed speech therapist’s treatment plan must contain the following: Diagnosis and date of onset of the client’s condition. Client’s rehabilitation potential. Modalities. Frequency. Duration (interpreted as estimated length of time until the client is discharged from speech therapy). Practitioner signature and date of review. Speech therapist’s notes and documented measurable progress and anticipated goals. Initial orders certifying the medical necessity for therapy. Practitioner’s renewal orders (at least every 180-days) certifying the medical necessity of continued therapy and any changes. The ordering practitioner must certify that: o The services are medically necessary. o A well-documented treatment plan is established and reviewed by the practitioner at least every 180-days. o Outpatient speech therapy services are furnished while the client is under their care. Total treatment minutes of the client, including those minutes of active treatment reported under the timed codes and those minutes represented by the untimed codes, must be documented, to include beginning time and ending time for services billed. Practitioners and licensed speech therapist’s progress notes must be completed for each date of service and contain the following: Identification of the client on each page of the treatment record; Identification of the type of therapy being documented on each entry (i.e., 97530 vs. 97110); Date and time(s) spent in each therapy session; total treatment minutes of the client, including those minutes of active treatment reported under timed codes and those minutes represented by the untimed codes, must be documented, to include beginning time and ending time for each service billed; Description of therapy activities, client reaction to treatment and progress being made to stated goals/outcomes; Full signature or counter signature of the licensed therapist, professional title and date that entry was made and the signature of the therapy assistant and date the entry was made. Licensed therapist must sign progress notes of assistants within 30-days. Ch. 26 Index 344 Revision 4/1/17 Covered Services – Therapy Service_______________________________________________ 26.3.4 Cap Limits Medicaid clients will be limited to 20 speech therapy visits per year. If the client has exceeded the Medicaid limits on speech therapy visits, the provider may bill him/her, or request the cap limit be waived, as long as the services are still medically necessary (6.9, Cap Limits). Ch. 26 Index 345 Revision 4/1/17 Covered Services – Appendix____________________________________________________ Appendix Page left blank intentionally 346 Revision 4/1/17 APPENDIX A – CMS1500 Manual Version Control Table Revision Date 4/1/17 Change(s) 2.1 Quick Reference – Added HealthHelp to the table of contacts 3.2.3 Missed Appointments – Section re-written 6.8.1 Cap Limit Waiver – Form and instruction updated 6.14 Prior Authorization – Added HealthHelp to the table Chapter Seven – TPL/Medicare - Completely re-written Chapter Thirteen – Behavioral Health – Several changes throughout chapter APPENDIX B – Provider Notifications Log Email / Mail / Active Date(s) Notification Type 1/26/17 Email Notice 1/30/17 RA Banner 2/1/17 Email Notice 2/27/17 Email Notice 3/1/17 Email Notice 3/6/17 RA Banner 3/23/17 RA Banner Title Child Development Center Enrollment Requirements Humidifier RA Banner Physician Administered Drugs FCBC Behavioral Health & Substance abuse Option Manual Colorectal Cancer Screening Program Medicare Pricing Audience All Providers DME Physicians, Nurses DME, Home Health Behavioral Health Physicians, Hospitals All Providers Wyoming Medicaid Provider Enrollment Requirement – ACTION REQUIRED Wyoming Medicaid is mandated by federal policy to enroll all providers rendering services to clients for reimbursement through the Medicaid program. Currently, the CDCs are enrolled as individual payto entities. This means that on any given claim from a CDC, there is no listing of which therapist provided services to the client for which Wyoming Medicaid is reimbursing. In order to comply with federal regulations, this process must be updated to have the CDCs enrolled as groups (the pay-to provider) with treating (rendering) providers. Wyoming Medicaid will require that the CDCs begin billing as groups with dates of service 6/1/17 and newer. Before this date, each CDC will need to enroll as a group and enroll the providers who are providing services to the clients in their facility. This includes Physical, Occupational, and Speech Therapists and Behavioral Health providers (licensed professional counselors (LPC), licensed marriage and family therapists (LMFT), licensed clinical social workers (LCSW), licensed addiction therapists (LAT), and provisional licensed mental health professionals) The enrollment process is conducted online. After submitting the online portion of the enrollment, you will mail in the documents that require signature and copies of supporting documentation as required (license, NPI confirmation, etc.). Once all of the paperwork is received, it generally takes about 4 – 6 weeks for the enrollment to complete processing, so, please do not wait until the last minute to begin this process. You will not be able to bill for any dates of service 6/1/17 or after until this process is completed. The first enrollment you will need to complete will be for the CDC to establish the group, then complete enrollments for – http://wymedicaid.acslect – When enrolling the CDC as a group, the Type of Enrollment will be Group Practice. For all individual treating providers enrolled, the Type of Enrollment w selecting the taxonomy for the CDC enrollment, choose the Taxonomy Category DHCF Allowances and Taxonomy Description of 261Q00000X – the therapists, choose either Respiratory, Developmental, Rehabilitative & Restorative Service Providers (PT/OT), Speech, Language and Hearing Service Providers (ST) or Behavioral Health & Social Service Providers (Behavioral Health Providers) and then select the appropriate taxonomy under “Are you a member of a group practice, or do you work for a hospital that bills for you?” as yes – this will allow you to enter the CDCs NPI to link the individual therapist to the CDC for billing purposes. Enrollment tutorials are available on the web site here: https://wyequalitycare.acsinc.com/aca_reenrollment.html. Although these were created for the DD Waiver providers, they are still very useful for other providers to get an idea of the enrollment process. If you have any questions, contact Provider Relations at 800-251-1268, options 2, 1, 2 to speak with enrollment. While I am happy to try to answer questions for you, I do not have access to the tools and resources to review enrollment information, and the Provider Relations Call Center will be able to assist you much more timely and effectively. If you wish to contact me, email is the best choice, and I can be reached at amy.buxton@wyo.gov. Begin Date: 1/26/17 End Date: 2/23/17 Audience: DME ********************************************************************** Effective with dates of service 2/1/17 - Wyoming Medicaid will cover the purchase of the humidifier (E0562) with a CPAP or BiPAP machine when the item is not an integrated part of the machine. ********************************************************************** To view this email as a web page, go here. 2/1/17 Medicaid Website Manuals & Bulletins Fee Schedules What's New Links IVR Navigation Tips Web Portal Tutorials Effective March 1, 2017, Wyoming Medicaid will be standardizing its methodology for the reimbursement of physician administered drugs. Rates will be established by using the drug's Average Sales Price (ASP) rate as published by Center for Medicare and Medicaid Services (CMS). Rates will be reviewed at least annually. For drugs that are not listed on the ASP file published by CMS, W yoming Medicaid will first reimburse the Wholesale Acquisition Cost (WAC), and if no WAC is available, will default to the Average W holesale Price (AWP) for the drug based on the CPT/HCPCS submitted on the claim form. Rates will be made available for viewing on the th W yoming Medicaid fee schedule no later than February 20 , 2017 to allow providers to evaluate specific impacts based on common drugs administered to W yoming Medicaid clients. As an important reminder for providers billing physician administered drugs, the units billed MUST be the CPT/HCPCS units appropriate for the dose administered. The units reported on the claim should NOT be the NDC-based units. Additionally, the applicable NDC for the drug administered must also be included on each claim. Help identify and combat Medicaid Fraud by visiting the website or contacting the Fraud Hotline: • http://stopmedicaidfraud.wyo.gov • 1-855-846-2563 WYhealth is a Medicaid health management and utilization management program offered by the Wyoming Department of Health through Optum. Medicaid clients and providers will benefit from a wide array of programs and services offered and coordinated by Optum. Visit www.wyhealth.net for more information This bulletin was sent on: Date: 2/1/17 Time: 3:00pm MST Audience: Physicians and Nurses 2/27/17 Medicaid Website Manuals & Bulletins Fee Schedules What's New Links IVR Navigation Tips Web Portal Tutorials As required under 42 CFR 455.434, starting July 1, 2017 Wyoming Medicaid will require all currently enrolled, newly enrolling and re-enrolling Home Health and Durable Medical Equipment/ Prosthetics and Orthotics Suppliers (DME/POS) to complete a full criminal background check as a condition of continued participation (if you haven't already done so through Medicare or another state's Medicaid program). This will require submitting fingerprints to the Wyoming Division of Criminal Investigation (DCI). Any Home Health or DME/POS owner who reported more than a 5% direct or indirect ownership interest upon enrollment with Medicaid will also be subject to the same fingerprint and background check requirements. Wyoming Medicaid is in the process of auditing current enrollment records to identify which enrolled providers will be required to complete this process. If your office is determined to need additional background checks completed, you will receive a more detailed letter with instructions on how to complete the fingerprinting process and a timeframe for completion. Any provider who has failed to comply with the fingerprinting and background check requirements by July 1, 2017 will be dis-enrolled from the WY Medicaid program. Please watch all upcoming communications carefully for more detailed information. For any further questions, please contact Andrew Chapin, Quality Assurance Manager Andrew.Chapin@wyo.gov. Help identify and combat Medicaid Fraud by visiting the website or contacting the Fraud Hotline: • http://stopmedicaidfraud.wyo.gov • 1-855-846-2563 WYhealth is a Medicaid health management and utilization management program offered by the Wyoming Department of Health through Optum. Medicaid clients and providers will benefit from a wide array of programs and services offered and coordinated by Optum. Visit www.wyhealth.net for more information Deployed: Date: 2/27/17 Time: 3pm MST Audience: DME and Home Health To view this email as a web page, go here. 3/3/17 Medicaid Website Manuals & Bulletins Fee Schedules What's New Links IVR Navigation Tips Web Portal Tutorials Attention Behavioral Health Providers Wyoming Medicaid Program, Community Mental Health & Substance Abuse Treatment Services Manual Effective April 1, 2017, the Wyoming Medicaid Program, Community Mental Health & Substance Abuse Treatment Services Manual, also known as the Medicaid Policies and Procedures Manual for Mental Health Substance Abuse Option Services will be discontinued. Any of the pertinent information that was in that manual has been transferred over to the CMS-1500 Provider Manual. Limitations for Behavioral Health Services When providing behavioral health services to a Medicaid client, the documentation kept must be accurate with the date and times the services were rendered (CMS-1500 Provider Manual 3.11 Record Keeping, Retention and Access, 13.9 Documentation Requirements for All Behavioral Health Providers). Behavioral health services cannot overlap date and time for a client. For example, a client being seen for group therapy on February 28th from 11:00 to 12:00 cannot also be seen for targeted case management on February 28th from 11:00 to 12:00. These are overlapping services and cannot be billed to Medicaid. Proper documentation of services includes the start and end times of the services being rendered. Rehabilitative vs. Habilitative Services Wyoming Medicaid coverage of rehabilitative services such as mental health and/or substance abuse treatment is limited to restorative treatment only. Maintenance therapy is not a covered service by Wyoming Medicaid. Health Resources and Services Administration has historically differentiated between habilitation and rehabilitation services and does not allow for the inclusion of habilitation services under the rehabilitation benefit category (State Plan Medicaid). Habilitation services, which are services to assist an individual in obtaining a skill, are not included in the section 1905(a) list of services and are only available in an institution for the developmentally disabled or under a home and community based services waiver. Habilitation services cannot be covered as "rehabilitative" when they are furnished to individuals, for example, suffering from a mental retardation or to children experiencing development delays, because services are assisting the child in obtaining a skill rather than restoring lost capabilities. To better understand the difference between habilitative and rehabilitative services, the key is whether or not the person ever had the skill or function. If the person did have it and lost it due to a disease or accident then it would be a rehabilitative service. If the person never had it then it is a habilitative service. Because Wyoming Medicaid is restricted to the reimbursement of services that are exclusively rehabilitative and restorative in nature, the Medicaid Developmental Disability Waiver Program (operating as the Comprehensive and Supports Waiver in Wyoming) also includes coverage for habilitative therapy services (physical, speech, occupational, community integration and supported living services) beneficial to clients with a developmental disability, recognizing that most often the services needed by these clients are habilitative in nature, and do not meet the requirements of the rehabilitative services covered by traditional Medicaid. Behavioral Health Cap Limits and Waiver Requests Clients 21 years of age and older have a cap limit of 20 visits for behavioral health services. After a client has used all 20 of his or her visits, the therapist may complete the Cap Limit Waiver Request form to request additional visits. Click on the link to be taken to the Cap Limit Waiver Request Form : https://wymedicaid.acsinc.com/forms/Cap_Limit_Waiver_Request_Form_1_1_17.pdf. Be aware that cap limit waivers will only be granted for those requests that meet Wyoming Medicaid policy. The Cap Limit Waiver Request form will require both the narrative diagnosis and the ICD-10 diagnosis code(s) that apply to the client's condition. Please also note the form requests the pay-to provider information, NOT the treating therapist's information; however, the treating therapist must sign the form. Forms that do not contain all of the correct information when they are reviewed may cause claims to deny or may be returned for correction, depending on the information provided or missing. Note: For clients over the age of 21 served by the Developmental Disabilities Comprehensive or Supports waiver, additional services may be available as part of the client's waiver plan. These services have different rules and requirements. Please contact the client's case manager or the Behavioral Health Division for questions related to waiver services, plans of care, or IBAs. Help identify and combat Medicaid Fraud by visiting the website or contacting the Fraud Hotline: • http://stopmedicaidfraud.wyo.gov • 1-855-846-2563 WYhealth is a Medicaid health management and utilization management program offered by the Wyoming Department of Health through Optum. Medicaid clients and providers will benefit from a wide array of programs and services offered and coordinated by Optum. Visit www.wyhealth.net for more information Unsubscribe Be sure to add wycustomersvc@conduent.com to your address book to ensure the proper delivery of your Wyoming Medicaid updates and weekly payment summary information. Wyoming Medicaid, Provider Relations, PO BOX 667, Cheyenne, WY 82003 Please do not reply to this email with any customer service issues. Specific account inquiries will not be read. For assistance, contact Provider Relations at 1-800-251-1268. http://wymedicaid.acs-inc.com/contact.html Deployed: Date: 3/3/17 Time: 3pm MST Audience: Behavioral Health Providers ******************************************************************** The Colorectal Cancer Screening Program has changed the screening vouchers to an enrollment card. Effective immediately, the program will be issuing enrollment cards to newly eligible clients. For questions please call 1-800-264-1296. ******************************************************************** Running: Date: 3/6/17-5/6/17 Audience: Physicians, Nurses, Hospitals ********************************************************************** Attention All Providers: If you have questions regarding paid and/or denied Medicare X-Over claims, please see the Wyoming Medicaid website - What's New Section https://wymedicaid.acs-inc.com/new.html.If you are calling Wyoming Medicaid Provider Relations for questions regarding Medicare X-Over claims, please note due to increased call volumes, longer wait times can be expected. *********************************************************************** Deployed: Date: 3/22/17 Audience: All Providers
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