Tuesday, October 28, 2014

Why Medicare split the claim for process and when?

Splitting Claims for Processing

There are a number of prescribed situations where a claim is received for certain services that require the splitting of the single claim into one or more additional claims. The splitting of such a claim is necessary for various reasons such as proper recording of deductibles, separating expenses payable on a cost basis from those paid on a charge basis, or for accounting and statistical purposes. Split a claim for processing in the following situations:

• Expenses incurred in different calendar years cannot be processed as a single claim. A separate claim is required for the expenses incurred in each calendar year;

EXCEPTION FOR DURABLE MEDICAL EQUIPMENT REGIONAL CARRIERS (DMERCs):

Expendable items (disposable items such as blood glucose test strips and PEN nutrients) that will be used in a time frame that spans two calendar years and are required to be billed with appropriately spanned “from” and “to” dates of service may be processed on a single claim line. For these types of items, DMERCs must base pricing and deductible calculations on the “from” date, since that is the date when the item was furnished.

• A claim other than a DMERC claim that spans two calendar years where the “from” date of service is untimely but the “to” date of service is timely should be split and processed as follows:

1. Where the number of services on the claim is evenly divisible by the number of days spanned, assume that the number of services for each day is equal. Determine the number of services per day by dividing the number of services by the number of days spanned. Then split the claim into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.

2. Where the number of services on the claim is not evenly divisible by the number of days spanned and it is not otherwise possible to determine from the claim the dates of services, suspend and develop the claim in order to determine the dates of services. After determining the dates of services, split the claim accordingly into a timely claim and an untimely claim. Deny the untimely claim and process the timely claim.

• A claim containing both assigned and unassigned charges. Split assigned and unassigned services from non-participating physicians/suppliers into separate assigned and unassigned claims for workload counts and processing;

• Assigned claims from different physicians/suppliers (excluding group practices and persons or organizations to whom benefits may be reassigned). Process a separate claim for the services from each physician/supplier. Where the assigned claim is from a person or organization to which the physicians performing the services have reassigned their benefits, process all of the services as a single claim;

• A claim where there is more than one beneficiary on a single claim. There can only be one beneficiary per claim; and NOTE: Roster bills for covered immunization services furnished by mass immunizers may be submitted for multiple beneficiaries. You must create individual claims for each Medicare beneficiary based on the roster bill information.

• Outpatient physical therapy services furnished on a cost basis by a physician-directed clinic cannot be processed when combined on the same claim with other charge-related services by the clinic. Process the cost related services as a separate claim.

• If an unassigned claim includes services by an independent physical therapist together with other physician services, process the physical therapy services as a separate claim. Process an assigned claim from an independent physical therapist as a single claim.

• A claim that is a duplicate of a claim previously denied is treated as a new claim if there is no indication that the claim is a resubmittal of a previous claim with additional information, or there is no indication on the second claim that the beneficiary is protesting the previous determination.

• In a claim containing services from physicians/suppliers covering more than one carrier jurisdiction, the carrier receiving the claim must split off the services to be forwarded to another contractor and count the material within the local jurisdiction as a claim. The carrier receiving the transferred material must also count it as a separate claim.

• When services in a claim by the same physician/supplier can be identified as being both second/third opinion services and services not related to second/third opinion, the "opinion" services must be split off from the "non-opinion" services and counted as a separate claim. When one physician/supplier in an unassigned claim has provided the "opinion" service and another physician(s)/supplier(s) has provided the "non-opinion" services, the claim may not be split.
• Claims containing any combination of the following types of services must be split to process each type of service as a separate claim. These services are:
-- Physical therapy by an independent practitioner,
-- outpatient psychiatric, or
-- any services paid at l00 percent of reasonable charges.

(Any of these types of services may be combined on the same claim with any other type of service.)
Do not deviate from defining claims as described above. Split claims in accordance with the appropriate definition. Throughout the claims process count each of the separate claims, resulting from the split, as an individual claim.

Saturday, October 18, 2014

Medicare Definition of Clean Claim



A “clean” claim is one that does not require the carrier or FI to investigate or develop external to their Medicare operation on a prepayment basis. Clean claims must be filed in the timely filing period.
The following bullets are some examples of what are considered clean claims:

• Pass all edits (contractor and Common Working File (CWF)) and are processed electronically);

• Not require external development (i.e., are investigated within the claims, medical review, or payment office without the need to contact the provider, the beneficiary, or other outside source) (Note: these claims are not included in CPE scoring).

• Claims not approved for payment by CWF within 7 days of the FI’s original claim submittal for reasons beyond the carrier’s, FI’s or provider’s control (e.g., CWF system/communication difficulties);

• CWF out-of-service area (OSA) claims. These are claims where the beneficiary is not on the CWF host and CWF has to locate and identify where the beneficiary record resides;
• Claims subject to medical review but complete medical evidence is attached by the provider or forwarded simultaneously with EMC records in accordance with the carrier’s or FI’s instructions;
• Are developed on a postpayment basis; and,
• Have all basic information necessary to adjudicate the claim, and all required supporting documentation

Wednesday, October 8, 2014

License Update Policy - From Molina Healthcare

Health care providers, who under the state plan and/or state statute are required to be licensed in West Virginia (WV) or the state in which they practice, must maintain and ensure that a current license is on file at all times with the West Virginia Bureau for Medical  Services (BMS) Fiscal Agent, Molina.  A provider’s participation in the WV Medicaid program may be terminated if Molina cannot verify the current status of a provider’s license.

Effective October 1, 2009, the Provider License Update Reminder Process is as follows:

***  60 days prior to the license expiration date, an initial reminder letter will be sent to the provider’s correspondence address indicating their current license expiration date.  If an updated license is not received on or before the expiration date, the provider will be placed on pay hold.

***  If a provider fails to submit a copy of their updated license 30 days after the expiration date, Molina will check listings from the licensing boards.  If a provider’s license renewal date can be verified through the board listings, the pay hold will be re-moved.  If Molina cannot verify an effective license renewal date via the board listing, the provider will remain on pay hold.

***  A letter will be sent 30 days after the provider’s license expiration date to providers who have failed to submit their updated license. Molina will not verify license renewal through the licensing boards.  The provider will remain on pay hold until the updated license is sent to Molina.

***  60 days after the license expiration date, Molina will make a telephone call to those providers that have not submitted an updated license. Providers who have failed to send an updated license to Molina will remain on pay hold.

***  90 days after the license expiration date, Molina will determine which providers have not complied and submitted an updated license.  Providers who have not submitted an updated license will receive notification of intent to terminate if the updated license is not received within 30 days.

***  If after 121 days from the initial license expiration date Molina has not received the provider’s updated license, the provider’s claims will be voided from Accounts Payable and the provider will be terminated from West Virginia Medicaid.  A letter will be sent to the provider notifying them of the termination. Instructions on how to resubmit claims for payment for services ren-dered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not pay-able.  A listing of voided claims will accompany the letter.

***  Providers may mail or fax a copy of any license renewal information or other credential/ certification updates prior to expira-tion of the current license.  Mailing address:  Molina Provider Enrollment, PO Box 625, Charleston, WV 25322.  Fax: Provid-er Enrollment 304-348-2763.

***  All providers who have mailed or faxed their updated license will continue their Medicaid enrollment without interruption.

Tuesday, September 23, 2014

Billing Medicare - Medicaid patient . Explanation of different Medicaid plan and its coverage

Dual Eligible Beneficiaries

Dual eligible beneficiaries include individuals who receive full Medicaid benefits as well as those who only receive assistance with Medicare premiums or cost sharing. They must meet certain income and resource requirements and be entitled to Medicare Part A and/or Part B and one of the following Medicaid Programs:

• Full Medicaid; or
• Special Need Plans, which include the following four programs:
○ Qualified Medicare Beneficiary (QMB) Program;
○ Specified Low-Income Medicare Beneficiary (SLMB) Program;
○ Qualifying Individual (QI) Program; and
○ Qualified Disabled Working Individual (QDWI) Program.

Dual eligible beneficiaries may choose coverage under FFS Medicare or a MA Plan. Medicare-covered services are paid first by Medicare because Medicaid is always
the payer of last resort. Medicaid may cover the cost of prescription drugs and other care that Medicare does not cover

Full Medicaid

Its coverage either categorically or throught optional coverage groups based on medically need status. Special income levels for institutionalized individuals or home and community based waivers

Medicaid pays for part A and part B premiums and cost sharing for Medicare providers to the extent consistent with Medicaid state plan

QMB Only

Medicaid pays for part A AND Part B premiums, deductibles, coinsurance and copayments for Medicare services furnished by Medicare providers to the extent consisten with Medicaid state plan

SLMB Only
• Medicaid pays for Part B premiums

Prohibited Billing
Under Section 1902(n)(3)(B) of the Social Security Act, as modified by Section 4714 of the Balanced Budget Act of 1997, Medicare and Medicaid payments you receive for furnishing services to a QMB are considered payments in full. You may not balance bill QMBs for any Medicare cost sharing (including deductibles, coinsurance, and copayments) for these services. You are subject to sanctions if you bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing).

We could only bill patient if they SLMB plan.

Thursday, September 18, 2014

Exceptions Allowing Extension of Time Limit

Medicare regulations at 42 C.F.R. §424.44(b) allow for the following exceptions to the 1 calendar year time limit for filing fee for service claims:

(1) Administrative error, if failure to meet the filing deadline was caused by error or misrepresentation of an employee, Medicare contractor, or agent of the Department that was performing Medicare functions and acting within the scope of its authority (See 70.7.1).

(2) Retroactive Medicare entitlement, where a beneficiary receives notification of Medicare entitlement retroactive to or before the date the service was furnished. For example, at the time services were furnished the beneficiary was not entitled to Medicare. However, after the timely filing period has expired, the beneficiary subsequently receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service (See 70.7.2).

(3) Retroactive Medicare entitlement involving State Medicaid Agencies, where a State Medicaid Agency recoups payment from a provider or supplier 6 months or more after the date the service was furnished to a dually eligible beneficiary. For example, at the time the service was furnished the beneficiary was only entitled to Medicaid and not to Medicare. Subsequently, the beneficiary receives notification of Medicare entitlement effective retroactively to or before the date of the furnished service. The State Medicaid Agency recoups its money from the provider or supplier and the provider or supplier cannot submit the claim to Medicare, because the the timely filing limit has expired

Retroactive disenrollment from a Medicare Advantage (MA) plan or Program of All-inclusive Care of the Elderly (PACE) provider organization, where a beneficiary was enrolled in an MA plan or PACE provider organization, but later was disenrolled from the MA plan or PACE provider organization retroactive to or before the date the service was furnished, and the MA plan or PACE provider organization recoups it payment from a provider or supplier 6 months or more after the date the service was furnished

The conditions for meeting each exception, and a description of how filing extensions will be calculated, are described in sections 70.7.1 – 70.7.4.


Where the initial request for an exception to the timely filing limit is made by a provider or supplier, the Medicare contractor has responsibility for determining whether a late claim may be honored based on all pertinent documentation submitted by the provider or supplier, and for the exceptions described in sections 70.7.2 and 70.7.3, based on its review of the relevant information contained in the Common Working File (CWF) database. As explained in sections 70.7.1 – 70.7.4, the contractor will determine if the requirements for a particular exception are met. However, in certain circumstances, the contractor may contact the appropriate CMS regional office (RO) to ascertain whether it wants to participate in the review and decision-making of the specific exception request. In limited circumstances, the RO may conclude that the exception request should go to CMS Central Office for a final determination.

Medicare physician fee schedule - Quick overview

Medicare Part B pays for physician services based on the PFS, which lists the more than 7,400 unique
covered services and their payment rates. Physicians’ services include the following:

* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.


Medicare Physician Fee Schedule Payment Rates

Payment rates for an individual service are based on
three components:
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)


Medicare Physician Fee Schedule Payment Rates Formula


The Medicare PFS payment rates formula is shown below:

[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF

Medicare fee schedule download