Pathology billing - Medicare payment guidelines


Payment for Pathology Services


A.Payment for Professional Component (PC) Services

Payment may be made under the physician fee schedule for the professional component of physician laboratory or physician pathology services furnished to hospital inpatients or outpatients by hospital physicians or by independent laboratories, if they qualify as the
re-assignee for the physician service.

B.Payment for Technical Component (TC) Services

1.General Rule


Payment is not made under the physician fee schedule for TC services furnished in institutional settings where the TC service is bundled into the facility payment, e.g., hospital inpatient and outpatient settings. Payment is made under the physician fee schedule for TC services furnished in institutional settings where the TC service is not bundled into the facility payment, e.g., an ambulatory surgery center (ASC).

Payment may be made under the physician fee schedule for the TC of physician pathology services furnished by an independent laboratory, or a hospital if it is acting as an independent laboratory, to non-hospital patients. The physician fee schedule identifies physician laboratory or physician pathology services that have a TC service.

2.TC Services Furnished by Independent Laboratories to Hospital Inpatients and Outpatients


*For services furnished on or after July 1, 2012, an independent laboratory may not bill the Medicare contractor (and the Medicare contractor may not pay) for the TC of a physician pathology service furnished to a hospital inpatient or outpatient.

*For services furnished prior to July 1, 2012, payment may be made under the fee schedule, as noted below, for the (TC) of pathology services furnished by an independent laboratory to hospital inpatients or outpatients.

CMS published a final regulation in 1999 that would no longer allow independent laboratories to bill under the physician fee schedule for the TC of physician pathology services. The implementation of this regulation was delayed by Section 542 of the Benefits and Improvement and Protection Act of 2000 (BIPA). Section 542 allows the Medicare carrier to continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. This provision is applicable to TC services furnished January 1, 2001 through June 30, 2012.

For this provision, a covered hospital is a hospital that had an arrangement with an independent laboratory that was in effect as of July 22, 1999, under which a laboratory furnished the TC of physician pathology services to fee-for-service Medicare beneficiaries who were hospital inpatients or outpatients, and submitted claims for payment for the TC to a carrier. The TC could have been submitted separately or combined with the professional component and reported as a combined service.

The term, fee-for-service Medicare beneficiary, means an individual who:

*Is entitled to benefits under Part A or enrolled under Part B of title XVIII or both; and

*Is not enrolled in any of the following: A Medicare + Choice plan under Part C of such title; a plan offered by an eligible organization under §1876 of the Social Security Act; a program of all-inclusive care for the elderly under
§1894; or a social health maintenance organization demonstration project established under Section 4108 of the Omnibus Budget Reconciliation Act of 1987.

In implementing Section 542, the contractors should consider as independent laboratories those entities that it has previously recognized as independent laboratories.

An independent laboratory that has acquired another independent laboratory that had an arrangement of July 22, 1999, with a covered hospital, can bill the TC of physician pathology services for that hospital’s inpatients and outpatients under the physician fee schedule.

An independent laboratory that furnishes the TC of physician pathology services to inpatients or outpatients of a hospital that is not a covered hospital may not bill the carrier for the TC of physician pathology services during the time §542 is in effect.

If the arrangement between the independent laboratory and the covered hospital limited the provision of TC physician pathology services to certain situations or at particular times, then the independent laboratory can bill the carrier only for these limited services.

The contractor shall require independent laboratories that had an arrangement, on or prior to July 22, 1999 with a covered hospital, to bill for the technical component of physician pathology services to provide a copy of this agreement, or other documentation

substantiating that an arrangement was in effect between the hospital and the independent laboratory as of this date. The independent laboratory must submit this documentation for each covered hospital that the independent laboratory services.

C.Physician Laboratory and Pathology Services

Physician laboratory and pathology services are limited to:

*Surgical pathology services;

*Specific cytopathology, hematology and blood banking services that have been identified to require performance by a physician and are listed below;

*Clinical consultation services that meet the requirements in subsection 3 below; and

*Clinical laboratory interpretation services that meet the requirements and which are specifically listed in subsection 4 below.

1.Surgical Pathology Services

Surgical pathology services include the gross and microscopic examination of organ tissue performed by a physician, except for autopsies, which are not covered by Medicare.

Depending upon circumstances and the billing entity, the contractors may pay professional component, technical component or both.

2.Specific Hematology, Cytopathology and Blood Banking Services

Cytopathology services include the examination of cells from fluids, washings, brushings or smears, but generally excluding hematology. Examining cervical and vaginal smears are the most common service in cytopathology. Cervical and vaginal smears do not require interpretation by a physician unless the results are or appear to be abnormal. In such cases, a physician personally conducts a separate microscopic evaluation to determine the nature of an abnormality. This microscopic evaluation ordinarily does require performance by a physician. When medically necessary and when furnished by a physician, it is paid under the fee schedule.

For services furnished prior to January 1, 1999, contractors pay separately under the physician fee schedule for the interpretation of an abnormal pap smear furnished to a hospital inpatient by a physician. They must pay under the clinical laboratory fee schedule for pap smears furnished in all other situations. This policy also applies to screening pap smears requiring a physician interpretation. For services furnished on or after January 1, 1999, contractors allow separate payment for a physician’s interpretation of a pap smear to any patient (i.e., hospital or non-hospital) as long as: (1) the

laboratory’s screening personnel suspect an abnormality; and (2) the physician reviews and interprets the pap smear.

This policy also applies to screening pap smears requiring a physician interpretation and described in the National Coverage Determination Manual and Chapter 18. These services are reported under codes P3000 or P3001.

Physician hematology services include microscopic evaluation of bone marrow aspirations and biopsies. It also includes those limited number of peripheral blood smears which need to be referred to a physician to evaluate the nature of an apparent abnormality identified by the technologist. These codes include 85060, 38220, 85097, and 38221.

Contractors pay the PC for the interpretation of an abnormal blood smear (code 85060) furnished to a hospital inpatient by a hospital physician or an independent laboratory. For other hematology codes, payment may be made for the PC component if the service is furnished to a patient by a hospital physician or independent laboratory. In addition, payment may be made for these services furnished to patients by an independent laboratory.

Blood banking services of hematologists and pathologists are paid under the physician fee schedule when analyses are performed on donor and/or patient blood to determine compatible donor units for transfusion where cross matching is difficult or where contamination with transmissible disease of donor is suspected.

The blood banking codes are 86077, 86078, and 86079 and represent professional component only services.

3.Clinical Consultation Services

Clinical consultations are paid under the physician fee schedule only if they:

a.Are requested by the patient’s attending physician;

b.Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;

c.Result in a written narrative report included in the patient’s medical record; and

d.Require the exercise of medical judgment by the consultant physician.

Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.

Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met. Laboratory personnel, including the director, may from time to time contact attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters. These contacts do not constitute clinical consultations. However, if in the course of such a contact, the attending physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.

EXAMPLE: A pathologist telephones a surgeon about a patient’s suitability for surgery based on the results of clinical laboratory test results. During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient history and medical records, the patient is a candidate for surgery. The surgeon’s request requires the pathologist to render a medical judgment and provide a consultation. The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patient’s medical record that he/she requested a consultation. This consultation is paid under the fee schedule.

In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.

See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.

4.Clinical Laboratory Interpretation Services

Only clinical laboratory interpretation services, which meet the criteria in subsections C.3.a, c, and d, are billable under the physician fee schedule. These codes have a PC/TC indicator of “6” on the Medicare Physician Fee Schedule database. These services are reported under the clinical laboratory code with modifier 26. These services can be paid under the physician fee schedule if they are furnished to a patient by a hospital pathologist or an independent laboratory. Note that a hospital’s standing order policy can be used as a substitute for the individual request by the patient’s attending physician.

Contractors are not allowed to revise CMS’s list to accommodate local medical practice. The CMS periodically reviews this list and adds or deletes clinical laboratory codes as warranted.

D.Global Billing


Billing globally for services that are split into separate PC and TC services is only possible when the PC and TC are furnished by the same physician or supplier entity. For example, where the PC and the TC of a diagnostic service are provided in the same service location, this is reflected as the address entered into Item 32 on CMS Form 1500, which provides the ZIP Code to pay the right locality/GPCI. In this case, the physician/entity may bill globally. However, if the PC and the TC are each provided in different service locations (enrolled practice locations), the PC and the TC must be separately billed.


Merely applying the same place of service (POS) code to the PC and the TC does not permit global billing for any diagnostic procedure.

CPT 99490, 99487, 99489 - Chronic Care Management Services - Medicare guidelines

Chronic Care Management Services
 - CCM

CPT 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

● Comprehensive care plan established, implemented, revised, or monitored


Complex CCM

CPT 99487 Complex chronic care management services, with the following required elements:

● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient

● Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline

● Establishment or substantial revision of a comprehensive care plan

● Moderate or high complexity medical decision making

● 60 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month

CPT 99489 Each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)

Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately.

Report 99489 in conjunction with 99487. Do not report 99489 for care management services of less than 30 minutes additional to the first 60 minutes of complex CCM services during a calendar month. CCM (sometimes referred to as “non-complex” CCM) and complex CCM services share a common set of service elements (summarized in Table 1). They differ in the amount of clinical staff service time provided; the involvement and work of the billing practitioner; and the extent of care planning performed.


Only one practitioner may be paid for CCM services for a given calendar month. This practitioner must only report either complex or non-complex CCM for a given patient for the month (not both).

Practitioner Eligibility

Physicians and the following non-physician practitioners may bill CCM services:

● Certified Nurse Midwives

● Clinical Nurse Specialists

● Nurse Practitioners

● Physician Assistants

NOTE: CCM may be billed most frequently by primary care practitioners, although in certain circumstances specialty practitioners may provide and bill for CCM. The CCM service is not within the scope of practice of limited license physicians and practitioners such as clinical psychologists, podiatrists, or dentists, although practitioners may refer or consult with such physicians and practitioners to coordinate and manage care.

CCM services that are not provided personally by the billing practitioner are provided by clinical staff under the direction of the billing practitioner on an “incident to” basis (as an integral part of services provided by the billing practitioner), subject to applicable State law, licensure, and scope of practice. The clinical staff are either employees or working under contract to the billing practitioner whom Medicare directly pays for CCM. Time spent directly by the billing practitioner or clinical staff counts toward the threshold clinical staff time required to be spent during a given month in order to bill CCM services. Non-clinical staff time cannot be counted toward the threshold.

Supervision

The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required. Patient Eligibility Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline are eligible for CCM services.

● Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.

● There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities.

The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both.

Examples of chronic conditions include, but are not limited to, the following:

● Alzheimer’s disease and related dementia
● Arthritis (osteoarthritis and rheumatoid)
● Asthma
● Atrial fibrillation
● Autism spectrum disorders
● Cancer
● Cardiovascular Disease
● Chronic Obstructive Pulmonary Disease
● Depression
● Diabetes
● Hypertension
● Infectious diseases such as HIV/AIDS


Initiating Visit

For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner). This initiating visit is not part of the CCM service and is separately billed.

Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualified health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]). G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.

Patient Consent

Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical
record, and includes informing them about:

● The availability of CCM services and applicable cost-sharing

● That only one practitioner can furnish and be paid for CCM services during a calendar month

● The right to stop CCM services at any time (effective at the end of the calendar month)


Informed patient consent need only be obtained once prior to furnishing CCM, or if the patient chooses to change the practitioner who will furnish and bill CCM.
CCM Service Elements - Highlights The CCM service is extensive, including structured recording of patient health information, maintaining a comprehensive electronic care plan, managing transitions of care and other care management services, and coordinating and sharing patient health information timely within and outside the practice.

Table 1 summarizes the CCM service elements, which apply to both complex and non-complex CCM unless otherwise specified. CCM services are typically provided outside of face-to-face patient visits, and focus on characteristics of advanced primary care such as a continuous relationship with a designated member of the care team; patient support for chronic diseases to achieve health goals; 24/7 patient access to care and health information; receipt of preventive care; patient and caregiver engagement; and timely sharing and use of health information.


Structured Recording of Patient Health Information

● Record the patient’s demographics, problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology. This means a version of certified EHR that is acceptable under the EHR Incentive Programs as of December 31st of the calendar year preceding each Medicare PFS payment year. For more information, visit https://www.cms.gov/Regulations-and-Guidance/Legislation/ EHRIncentivePrograms.

Comprehensive Care Plan

● A person-centered, electronic care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues, with particular focus on the chronic conditions being managed)

● Provide the patient and/or caregiver with a copy of the care plan

● Ensure the electronic care plan is available and shared timely within and outside the billing practice to individuals involved in the patient’s care

● Care planning tools and resources are publicly available from a number of organizations (see Resources in Table 2)


Comprehensive Care Plan

A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:
● Problem list
● Expected outcome and prognosis
● Measurable treatment goals
● Symptom management
● Planned interventions and identification of the individuals responsible for each intervention
● Medication management
● Community/social services ordered
● A description of how services of agencies and specialists outside the practice will be directed/coordinated
● Schedule for periodic review and, when applicable, revision of the care plan



Access to Care & Care Continuity

● Provide 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, including providing patients (and caregivers as appropriate) with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week

● Ensure continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments

● Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care by telephone and also through secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods (for example, email or secure electronic patient portal)
 Comprehensive Care Management

● Systematic assessment of the patient’s medical, functional, and psychosocial needs

● System-based approaches to ensure timely receipt of all recommended preventive care services

● Medication reconciliation with review of adherence and potential interactions

● Oversight of patient self-management of medications

● Coordinating care with home and community based clinical service providers


Transitional Care Management

● Manage transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after an emergency department visit, or facility discharge

● Timely create and exchange/transmit continuity of care document(s) with other practitioners and providers Concurrent Billing

The billing practitioner cannot report both complex CCM and non-complex CCM for a given patient for a given calendar month. CCM cannot be billed during the same service period as HCPCS codes G0181/G0182 (home health care supervision/hospice care supervision), or CPT codes 90951–90970 (certain End-Stage Renal Disease services). CCM should not be reported for services furnished during the 30-day transitional care management service period (CPT 99495, 99496). Complex CCM and prolonged Evaluation and Management (E/M) services cannot be reported the same calendar month. Consult CPT instructions for additional codes that cannot be billed concurrent with CCM. There may be additional restrictions on billing for practitioners participating in a CMS sponsored model or demonstration program. Time that is reported under or counted
towards the reporting of a CCM service code cannot also be counted towards any other billed code.


Payment

CMS pays for CCM services separately under the Medicare PFS. To find payment information for a specific geographic location by code, access the Medicare PFS Look-Up tool at https://www.cms.gov/Medicare/ Medicare-Fee-for-Service-Payment/PFSlookup.

CCM and Other CMS Advanced Primary Care Initiatives

The CCM service codes provide payment of care coordination and care management for a patient with multiple chronic conditions within the Medicare Fee-For-Service Program. Medicare will not make duplicative payments for the same or similar services for patients with chronic conditions already paid for under the various CMS
advanced primary care demonstration and other initiatives, such as the Comprehensive Primary Care (CPC) Initiative. For more information on potentially duplicative billing, consult the CMS staff responsible for demonstration initiatives.


Initiating Visit – Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required), for new patients or patients not seen within 1 year prior to the commencement of CCM services.


Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications, and medication allergies using certified EHR technology. A full list of problems, medications, and medication allergies in the EHR must inform the care plan, care coordination, and ongoing clinical care.


24/7 Access & Continuity of Care

● Provide 24/7 access to physicians or other qualified health care professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week

● Continuity of care with a designated member of the care team with whom the patient is able to schedule successive routine appointments


Comprehensive Care Management – Care management for chronic conditions including systematic assessment of the patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.


Comprehensive Care Plan

● Creation, revision, and/or monitoring (as per code descriptors) of an electronic person-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues with particular focus on the chronic conditions being managed.

● Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the patient’s care.

● A copy of the plan of care must be given to the patient and/or caregiver.


Management of Care Transitions

● Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities ● Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers


Home- and Community-Based Care Coordination

● Coordination with home- and community-based clinical service providers

● Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record Enhanced Communication Opportunities – Enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non-face-to-face consultation
methods.


Patient Consent

● Inform the patient of the availability of CCM services; that only one practitioner can furnish and be paid for these services during a calendar month; and of their right to stop the CCM services at any time (effective at the end of the calendar month)

● Document in the patient’s medical record that the required information was explained and whether the patient accepted or declined the services


Medical Decision-Making – Complex CCM services require and include medical decision-making of moderate to high complexity (by the physician or other billing practitioner)


Medicaid - DME - Guidelines and coverage policies


DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, ORTHOTIC DEVICES, DISPOSABLE MEDICAL SUPPLIES (DMEPOS) PROGRAM

A.GENERAL INFORMATION

1.DMEPOS Program coverage areas include parenteral and enteral nutrition (PEN), medical foods and oxygen and oxygen equipment; all of which must meet the definition of durable medical equipment, a prosthetic device, an orthotic device, or disposable medical supply.

2.Durable Medical Equipment (DME) of a medical nature, needed as a result of a medical condition, and which lasts a considerable time without significant deterioration and appropriate for use within the home, is covered by the Division of Health Care Financing and Policy (DHCFP) and Nevada Check Up (NCU) for eligible recipients. Equipment repairs, or replacement requires medical documentation and is subject to limitations of model, cost and frequency, which are deemed reasonable by the program.

3.Disposable medical supplies are covered by the DHCFP and NCU for eligible recipients only if they are necessary for the treatment of a medical condition and would not generally be useful to a person in the absence of an illness, disability or injury.

4.All DMEPOS products and services must be medically necessary, safe and appropriate for the course and severity of the condition, using the least costly and equally effective alternative to meet the recipient’s medical needs.

5.Deluxe equipment will not be authorized when it is determined a standard model will meet the basic medical needs of the recipient. The recipient must have a medical need for each component of the item(s) requested. This includes accessory items and features not included in the standard models of the product.

6.Equipment which the program determines is principally for education or rehabilitation will not be approved.

7.Refer to Appendix A of this Chapter for non-covered services, and for special coverage considerations that are based on medical necessity outside of the DMEPOS Program or that is considered under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Healthy Kids Program.


8.Refer to Appendix B of this Chapter, for Coverage and Limitation Policies regarding specific coverage information, qualifications, documentation requirements, and miscellaneous information.

9.Refer to the Provider Type 33 DMEPOS Fee Schedule for specific item coverage under the DMEPOS program. Access http://dhcfp.nv.gov/Ratesunit.htm.

10.The DHCFP does not reimburse for items that are the same or similar to items that the recipient has already acquired, such as but not limited to back-up equipment, unless allowed in the specific policy for that item. Duplicate items intended to be used within the same span of time are not considered medically necessary.

11.Individuals deemed eligible for Nevada Medicaid or NCU and who have ownership of existing equipment from any prior resource must continue using that equipment. Existing equipment, regardless of who purchased it, must be identified, including the estimated date of purchase or age of equipment, and medical documentation showing evidence of need for replacement. All documentation must be submitted with a prior authorization request.

12.Some items not covered under the DMEPOS Program may be covered under other Medicaid programs such as Pharmacy, Audiology, or Ocular programs. Additional resources may be available through other agencies or through waiver programs for items not covered under the DMEPOS Program or by the Medicaid State Plan.

B.PROVIDER RESPONSIBILITY

1.All DMEPOS providers must be licensed through the Nevada State Board of Pharmacy (BOP) as a Medical Device, Equipment, and Gases (MDEG) supplier, with the exception of a pharmacy that has a Nevada State Board of Pharmacy license and provides DMEPOS. Once licensed, providers must maintain compliance with all Nevada BOP licensing requirements. Reference Medicaid Services Manual (MSM) Chapter 100 – Medicaid Program for further information on enrollment and provider responsibilities. Also refer to the Enrollment Checklist posted on the following website at: https://www.medicaid.nv.gov.

2.Suppliers of products covered under the Medicare Part B program are required to be enrolled in the Medicare Part B program in order to provide those services to Medicare and Medicaid dually eligible recipients. This includes obtaining and maintaining the Centers of Medicare and Medicaid Services (CMS) required accreditation and surety bond.

3.Potential providers who are not enrolled with the Medicare Part B program and who will not be supplying products covered under the Medicare Part B program to


individuals eligible for Medicare are required to provide a statement on/with their application that requests a waiver of the requirements for Medicare Part B enrollment. This statement must indicate that they do not service Medicare-eligible individuals and include a listing of the products they plan to supply.

4.A Medicaid-contracted DMEPOS provider may be reimbursed for services rendered to Medicaid eligible recipients when provided in accordance with established policies, guidelines and timeframes.

5.The provider is responsible for ensuring the equipment is appropriate for the recipient and the recipient’s residence prior to billing the DHCFP.

6.The provider is responsible for providing a manufacturer’s invoice for certain items, where no rate has been established.

7.The DMEPOS provider must comply with additional requirements as specified throughout this Chapter and its Appendices, Medicaid Services Manual (MSM) Chapter 100, the Provider Type (PT) 33 DMEPOS Fee Schedule, the Provider Billing Manual, and DMEPOS Billing Guidelines.

C.RECIPIENT RESPONSIBILITY

The eligible Nevada Medicaid or NCU recipient and/or their authorized representative will:

1.Make and keep appointments necessary for securing medical services/equipment;

2.Present current verification of Nevada Medicaid or NCU eligibility;

3.Present any forms or identification necessary to utilize other health insurance coverage;

4.Contact and return to the provider of services/equipment for any necessary adjustment within the time allotted for such adjustments;

5.Maintain the equipment provided by routinely cleaning and caring for the devices according to user information and supplier’s guidance. Provide safe, secure storage for item(s) when not in use to protect item(s) from loss or theft;

6.Not misuse, abuse or neglect purchased or rented item(s) in a way that renders the item(s) unsafe or non-usable;


7.Return all rented equipment to the DMEPOS provider when no longer being used, or upon the DME provider’s request. Failure to return rented equipment could result in a recipient’s financial responsibility for the retail price of the rented equipment, even if the equipment is lost/stolen, the recipient has moved, or they are no longer eligible for Nevada Medicaid/NCU.

8.Comply with additional requirements as specified throughout this Chapter and its Appendices and MSM Chapter 100.

DOCUMENTATION REQUIREMENTS

A.Supplier/provider records must substantiate the medical necessity for all DMEPOS items dispensed to recipients. The following describes the requirements for specific types of documentation associated with DMEPOS.

1.ORDERS / PRESCRIPTIONS

a.All DME items, Prosthetics, Orthotics, or Disposable Supplies (POS) dispensed must have an order/prescription from the treating physician or practitioner, (To determine included practitioners, refer to MSM, Chapter 600 – Physician’s Services), such as a Physician’s Assistant (PA), or Advanced Practitioner of Nursing (APN), when within their scope of practice and in accordance with federal and state laws governing  that entity, prior to dispensing the item.

In accordance with the Patient Protection and Affordable Care Act (PPACA) (The Affordable Care Act) of 2010 (Public Law 111-148), all orders for DMEPOS items, whether verbal or written, must be incidental to a physician-documented face-to-face encounter between the recipient and the prescribing physician/practitioner (as allowed by The Act) within 30 days prior to the start date of the order. The encounter must be relevant to the need for the prescribed DMEPOS.

Refer to Appendix B of this Chapter for additional order requirements on specific products.

General standards of care/practice mandate that if an order is not clear, a clarification of the order must be obtained from the ordering practitioner prior to acting on it.


b.Verbal Orders:

1.Verbal orders from the prescribing physician/practitioner may be accepted for DMEPOS items that do not require prior authorization by the DHCFP (except when Medicare is primary and Medicaid co- payment will be requested, and Medicare requires a written order for that item prior to delivery). Refer online to the DME MAC Jurisdiction D Supplier Manual, Chapter 3 – Documentation Requirements, for a current listing of those items at: https://www.noridianmedicare.com/dme/news/manual/chapter3.html

2.The verbal dispensing order must include:

a.A description of the item;

b.The recipient’s name;

c.The physician’s name;

d.The start date and length of need of the order; and

e.Additional information sufficient to allow appropriate dispensing of the item.

3.Suppliers must maintain written documentation of the verbal order and, if the verbal order is used for dispensing the item, the supplier must obtain a detailed written order prior to billing the DHCFP.

c.Written Orders:

1.Written orders are acceptable for all transactions involving DMEPOS and must be obtained prior to submitting a prior authorization for any DMEPOS items. Written orders may take the form of a photocopy, facsimile image, electronically maintained, or original “pen-and-ink” document.

2.All written orders must, at a minimum:

a.Clearly specify the start date of the order;

b.Include the length of need;


c.Be sufficiently detailed, including all options or additional features that are needed to meet the recipient’s needs. The description must be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number; and

d.Be signed and dated by the treating physician/practitioner. Signature includes computer signature and pen and ink, no signature stamps allowed.

3.Certain items require additional elements in the written orders, as follows:

a.If the written order is for supplies that will be provided on a periodic basis, the written order must include appropriate information on the quantity used, frequency of change, and duration of need. (For example, an order for surgical dressings might specify one 4x4-hydrocolloid dressing that is changed one to two times per week for one month or until the ulcer heals).

b.If the written order is for an item such as, but not limited to, enteral formula, oxygen, etc., the order must specify the name of the product, concentration (if applicable), dosage, frequency and route of administration, and duration of infusion (if applicable).

c.Custom-fabricated items must be clearly indicated on the written order that has been signed and dated by the prescribing physician/practitioner.

4.There are additional specifications for orders for certain items, such as, but not limited to, Power Mobility Devices (PMDs). Refer to Appendix B for details.

5.The detailed description of the item(s) may be completed by an employee of the ordering physician/practitioner; however, the prescriber must review the detailed description and personally indicate agreement by signing and dating the order.

6.Medical necessity information (such as the most current appropriate diagnosis code(s) (ICD) diagnosis code, narrative description of the recipient’s condition, abilities, and limitations) is not in itself


considered to be part of the order although it may be put on the same document as the order.

d.New Orders Are Required When:

1.There is a change in the order of a specific DMEPOS item;

2.There is a change in the resident’s condition that warrants a change in the order, a change in the treating physician/practitioner, or DMEPOS supplier;

3.An item is replaced for any reason; or

4.An ongoing unchanged order continues to be medically necessary one year after the original order (orders are only valid for up to one year, unless documented with a shorter length of time).

2.DETAILED PRODUCT DESCRIPTION

The detailed product description must contain the Healthcare Common Procedure Coding System (HCPCS) code, manufacturer, make and model, and the provider’s/supplier’s usual and customary charge for each item supplied. The warranty information must also be included. This may be completed by the provider/supplier but must also be signed and dated by the physician.

3.PROOF OF DELIVERY (POD)

A POD is a supplier’s delivery receipt, which is dated and timed.

NOTE: Item(s) ordered must be delivered within 120 days of the date of the order.

4.ADDITIONAL MISCELLANEOUS MEDICAL RECORDS

The recipient’s medical records must contain sufficient documentation of the recipient’s medical condition to substantiate the necessity for the type and quantity of items ordered and the frequency of the use or replacement. The information must include the recipient’s diagnosis and other pertinent information, including but not limited to: duration of recipient’s condition, clinical course (deteriorating or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. The records must include physician’s office records, hospital, nursing home or home health records, records from other professionals including but not limited to: nursing, physical and occupational therapists, prosthetists and orthotists, although


medical necessity for item(s) requested must be stated by the prescribing physician/practitioner.

5.ADVANCED DETERMINATION OF MEDICARE COVERAGE (ADMC)

When Medicare is the primary payer, for all items requiring an ADMC (refer online to the DME MAC Jurisdiction D, Supplier Manual, Chapter 9). The ADMC determination must be submitted to the Quality Improvement Organization (QIO)- like vendor at the same time the prior authorization is submitted.

B.PROVIDER RESPONSIBILITY

1.The provider must obtain the required documentation in a timely manner as described under each section listed previously.

2.The provider must maintain records at the physical location of their business for each item billed to, and paid by, the DHCFP for at least six years from the Remittance Advice (RA) date. At a minimum, this includes the original signed order/prescription, all supporting medical documentation, and proof of delivery.

3.The provider must maintain records in a readily accessible location and, for audit and investigation purposes, to make available upon request by Medicaid staff or its contractors, all supporting information related to prior authorizations, dispensed items, and/or paid clams for DMEPOS items.

RENTAL AND PURCHASE OPTIONS

Items identified in the DMEPOS Fee Schedule with a rental and purchase option require prior authorization to determine if the recipient’s needs justify rental or purchase based on the item prescribed, the individual’s anticipated length of need and prognosis (as determined by the prescriber) and cost effectiveness to the DHCFP and NCU.

a.RENTAL

1.In addition to all other requirements and qualifications for specific products, if the DMEPOS Fee Schedule allows a rental option, a device may be rented when:

a.the anticipated length of need (per physician’s/practitioner’s order) is short term (six months or less) and rental would be more cost effective than purchase;

b.a temporary trial period is required for the item according to Medicaid’s policy;


c.the item is only available as a rental per the DMEPOS Fee Schedule; or

d.a temporary rental is needed while a recipient-owned like item is being repaired.

2.During a rental period, rental rates include all supplies and accessories necessary to render the equipment useable and safe, delivery and set up services, education and training for recipient and family, routine maintenance and servicing (such as testing, cleaning, regulating and checking equipment), repairs, non-routine maintenance and servicing (such as breaking down sealed components and performing tests which require specialized equipment and skills of a technician), and replacement of items. These services are the responsibility of the owner, the DMEPOS supplier.

3.Throughout any rental period, there must be an active physician’s/practitioner’s order for ongoing use, the prior authorization effective dates are still applicable, and there is a continued medical need for the item. The DMEPOS supplier must contact the recipient or their representative within five business days prior to each billing cycle to verify the rented item is still medically necessary, in working condition, and being used by the recipient (contact does not include system generated correspondence). Verification must be documented and maintained in the DMEPOS supplier’s records and be accessible for audits.

4.Rent-to-Purchase Option:

a.The DHCFP allows rental of certain DMEPOS items up to the provider’s Usual and Customary Charge (UCC) for purchase, or the maximum Medicaid allowable purchase price of the item; whichever is less.

b.Unless the item is identified by Nevada Medicaid as a rental only, once the total cumulative rental payments have reached the lower of UCC or maximum Medicaid allowable purchase rate, the item is considered purchased in full and recipient-owned.

c.The provider shall automatically transfer the title for the equipment to the recipient. Providers are not to submit prior authorization to transfer titles. Providers are also not to submit prior authorizations coded as a purchase after the lower of UCC or Medicaid allowable purchase rate is reached. No rental or purchase payments will be made for the remaining reasonable useful lifetime of the device (usually not less than five years (60 months)). The provider’s records must include the date the title was transferred to the recipient.


d.When an item was new at the time of issuance, and it is later determined the recipient will need the item long term, rental payments will be applied toward the total purchase rate (either the provider’s UCC or the Medicaid allowable). Refer to “Purchase Used Equipment Option” in Section 1303.

e.Equipment that was not new at the time of issuance, such as items from the provider/supplier rental fleet, supplied as a temporary short term rental item must be replaced with new equipment as soon as it is identified the recipient will need the device long term (no later than in the sixth month of rental). Payments made on rental fleet-type items will not be applied to the purchase price of a new item. Purchase or transfer of titles to recipients when the used equipment is from a rental fleet is not allowed.

f.For this option, non-routine maintenance and servicing or repairs may be covered for service dates after the item is owned by the recipient; no sooner than the month following the last rental month.

5.Rental Only Option:

a.Certain items are identified by Nevada Medicaid as a rental only. For these items, a monthly rental will be allowed as long as the recipient continues to meet all qualifications and requirements, and the recipient continues to use the device.

b.For this option, the DMEPOS supplier retains ownership of the equipment, regardless of the length of rental. As the owner, the DMEPOS supplier is responsible to ensure the equipment remains in safe working condition for the reasonable useful lifetime of the device. The rental rates include all supplies and accessories, repairs including routine and non-routine maintenance and servicing, and replacement of items when needed.
b.PURCHASE

1.Purchase New Equipment Option:

a.Certain products are identified by Nevada Medicaid in the DMEPOS Fee Schedule with a purchase option for new equipment, or can only be purchased, such as disposable supplies and custom-made items which can only be used by that recipient. These will be considered for purchase when, in addition to all other requirements and qualifications for a specific item/device:

1.the anticipated length of need (per physician’s order) is long term (more than six months); and


2.the provider will be supplying a new device/item to the recipient; or

3.the item is only available for purchase.

2.Purchase Used Equipment Option:

a.Certain products are identified by Nevada Medicaid with a purchase option for used equipment. When an item was new at the time it was dispensed to a recipient for rental purposes, and prior to billing the third month of rental, it is determined the item will be needed indefinitely, the DHCFP may purchase the item for the recipient for ongoing use. The DHCFP does not purchase used equipment from the provider’s inventory of rental items used for re-issuance to same or multiple persons over time (rental fleets, etc.).

b.The DHCFP will only purchase used equipment when, in addition to all other requirements and qualifications for the item:

1.the recipient meets the criteria for purchase of new equipment;

2.the item was new when placed in the recipient’s use and has been used for less than three months; and

3.the item is currently being used by the same recipient during a trial period and it has been determined the length of need will now be indefinite.

c.A prior authorization must be submitted to request purchase of a used item, with all supportive medical documentation to show the date the item was initially issued to the recipient and that the recipient continues to have an ongoing need for the item.


PRIOR AUTHORIZATION

A.Prior authorization is a review conducted by the Quality Improvement Organization (QIO)-like vendor’s medical professionals who review the prior authorization form and any additional information submitted to evaluate medical necessity, appropriateness, location of service, and compliance with the DHCFP’s policy, prior to delivery of service. Reference the MSM, Chapter 100 and the general Billing Manual for detailed information on prior authorizations and Medicaid eligibility for all providers at: http://www.medicaid.nv.gov/providers/BillingInfo.aspx.


1.Submission:

a.Prior authorizations must be completed and submitted by a current Medicaid provider (requestor), and the approval must be received, prior to delivery of services. The exception to this is if the recipient is determined eligible for Medicaid retroactively or if number four of this section applies.

b.A prior authorization is required for most durable medical equipment, prosthetics, orthotics, and oxygen.

c.A Medicaid provider may submit the prior authorization electronically using the QIO-like vendor’s on-line prior authorization system or may fax or mail the prior authorization to the QIO-like vendor. For more information, refer to the prior authorization section posted at: https://www.medicaid.nv.gov.

d.Requestors must submit a prior authorization with the most appropriate HCPCS code available and may not unbundle items included in the HCPCS code description. If an item has a designated code available, the miscellaneous code cannot be used. Providers may contact the Medicare Pricing, Data Analysis and Coding (PDAC) contractor, or the DME MAC for guidance on correct coding.

e.Documentation requirements are the same regardless of which mode of submission is used (e.g. the on-line prior authorization system, faxed, or mailed). Documentation submitted for consideration of the request must include the physician’s order and must clearly support coverage qualifications and recipient’s medical need for the equipment. Failure to provide all of the supporting medical documentation in its entirety, and within the required timeframes, will result in a denial of the prior authorization request, regardless of mode of submission.

f.Unless otherwise stated in policy, a prior authorization may be submitted to request authorization to exceed established quantity limitations when the medical documentation supports medical necessity for the increased quantity or frequency.

2.Review Consideration:

a.In addition to the specifications mentioned previously, for reviewing the prior authorization, products and services must be medically necessary, safe and appropriate for the course and severity of the condition using the least costly equally effective alternative to meet the recipient’s needs.


b.The recipient must have a medical need for, and the requested item must be suitable for use within the home. Consideration will also be based on the recipient’s additional use of the item for the conditions in each of the environments the recipient is likely to encounter in their daily routines, such as, but not limited to: attending school, work, and shopping. This information must be included in the supportive documentation submitted with the prior authorization.

c.For durable medical equipment, prosthetics, orthotics, and disposable medical supplies and appliances where coverage and limitation policies have not been established within this Chapter or its Appendices, the DHCFP may defer to DME MAC Jurisdiction D, Local Coverage Determination (LCD) and policy articles for coverage and limitation criteria. These can be accessed at: http://www.noridianmedicare.com/dme. The item must meet the definition of durable medical equipment, prosthetic, orthotic, or disposable medical supply and must be necessary to meet the medical needs of the recipient, and must be part of the prescribing physician’s/practitioner’s Plan of Care (POC).

d.The DHCFP has the option of requesting an Independent Medical Evaluation (IME) to determine the recipient’s limitations and abilities to support medical necessity.

3.Prior Authorization Requirements for Third Party Liability (TPL) and Medicare Crossovers:

a.Refer to MSM, Chapter 100, for more information on TPL, and Medicare Crossovers and the requirements for securing prior authorizations.

4.Prior Authorization Emergency Situations:

a.In an emergency situation, when an order is received by the supplier after the QIO-like vendor working hours or over weekends or State holidays, dispensing of a 72-hour supply of those DMEPOS items that require prior authorization will be allowed only when:

1.A delay of 24 hours of treatment could result in very severe pain, loss of life or limb, loss of eyesight or hearing, injury to self, or bodily harm to others; and

2.The treating physician/practitioner indicates the most current appropriate diagnosis code(s)/ICD code on the prescription that supports the use of the emergency policy.


b.The provider/supplier must submit the prior authorization the next business day with all required supportive documentation. The documentation must include proof of the date and time the order was received by the supplier and documentation to support both 1303.4(a.)(1.) and (2.).

5.DMEPOS Specific Prior Authorization Forms:

All forms must be completed and submitted by a current Medicaid  provider. Forms used must be the most current version.

a.All Forms and Form Release Memorandums or instructions may be accessed at the DHCFP’s website: https://dhcfp.nv.gov/index/htm. The instructions provide detailed guidance on form completion requirements.

b.Specific DME prior authorization forms are found on the QIO-like vendor’s website: https://www.medicaid.nv.gov/providers/forms/forms.aspx. All DMEPOS items that require prior authorization must be requested on these forms and submitted electronically, by fax or by mail to the QIO-like vendor for approval.

c.Usage Evaluation – For Continuing Use of Bi-Level and Continuous Positive Airway Pressure (BIPAP and CPAP) Devices use the form, found on the QIO-like vendor’s website. This form may be completed and submitted for continuing usage of BIPAP or CPAP devices.

d.Mobility Assessment for Mobility Devices, Wheelchair Accessories and Seating Systems, form found on the QIO-like vendor’s website. This form must be submitted for all mobility devices, wheelchair accessories and seating systems.

6.Denied Prior Authorization Requests:

a.There are various processing levels associated with prior authorization requests which do not support medical necessity. These may include, but are not limited to: a contact to the provider by the QIO-like vendor, a system generated technical denial, a system generated denial or reduction of services, a provider-requested reconsideration, a provider-requested peer-to-peer review with the physician. For specific information on time limits and an explanation of each, refer to the general Billing Manual for all providers at: https://www.medicaid.nv.gov/providers/billinginfo.aspx.

b.If a prior authorization request is denied or reduced, the provider and recipient will be sent a Notice of Decision (NOD) with a citation/reason to


provide a general explanation of the denial. The provider may request consideration of the denial by submitting additional supportive information and requesting a “Reconsideration” in writing.

c.If a reconsideration is not appropriate or is also denied, the recipient may be entitled to request an appeal or hearing. Refer to MSM Chapter 3100 – Hearings.

B.COVERAGE AND LIMITATIONS

1.Coverage and limitations are explained throughout this Chapter, including its appendices. Appendix B details coverage qualifications, prior authorization documentation requirements, and limitations for specific items.

2.Refer to the Nevada Medicaid Provider Type 33 – DME Fee Schedule posted at: http://dhcfp.nv.gov/RatesUnit.htm for covered services. The Fee Schedule identifies covered services/items (listed in alpha-numeric order according to HCPCS code), and rates. Codes are updated yearly. Codes not included in the fee schedule after the yearly update are considered non-covered.

Provider signature requirements - Medical record

Signature Requirements

In the content of health records, each entry must be authenticated by the author. Authentication is the process of providing proof of the authorship signifying knowledge, approval, acceptance or obligation of the documentation in the health record, whether maintained in a paper or electronic format accomplished with a handwritten or electronic signature. Individuals providing care for the patient are responsible for documenting the care. The documentation must reflect who performed the service.

a. The handwritten signature must be legible and contain at least the first initial and full last name along with credentials and date. A typed or printed name must be accompanied by a handwritten signature or initials with credentials and date.

b. An electronic signature is a unique personal identifier such as a unique code, biometric, or password entered by the author of the electronic medical record (EMR) or electronic health record (EHR) via electronic means, and is automatically and permanently attached to the document when created including the author’s first and last name, with credentials, with automatic dating and time stamping of the entry. After the entry is electronically signed, the text-editing feature should not be available for amending documentation. Example of an electronically signed signature: “Electronically signed by John Doe, M.D. on MM/DD/YYYY at XX:XX A.M.”

c. A digital signature is a digitized version of a handwritten signature on a pen pad and automatically converted to a digital signature that is affixed to the electronic document. The digital signature must be legible and contain the first and last name, credentials, and date.

d. Rubber stamp signatures are not permissible. This provision does not affect stamped signatures on claims, which remain permissible.


Documentation of Medical Services


Medical records are expected to contain all the elements required in order to file and substantiate a claim for the services as well as the appropriate level of care, i.e., evaluation and management service (see Policy Memo No. 2). Each diagnosis submitted on the claim must be supported by the documentation in the patient’s medical record.

The contracting provider agrees to submit claims only when appropriate documentation supporting said claims is present in the medical record(s) which shall be made available for audit and review at no charge.

Letters/checklists are not acceptable as documentation of medical necessity and do not replace what should be in the complete medical record. Abbreviations must be those that are generally accepted by your peers and clearly translated to be understandable to the reviewer.

2. BCBSKS has adopted the following standards for documentation of medical services.

Each patient’s health record shall meet these requirements:

a. Be legible in both readability and content.

b. Contain only those terms and abbreviations that are or should be comprehensible to similar providers/peers.

c. Contain patient-identifying information on each page to ensure pages are not lost or misfiled.

d. Indicate the dates any professional service was provided and date of each entry.

e. Contain pertinent information concerning the patient’s condition and justify the course of treatment. The record must document the medical necessity and appropriateness of each service.
f. Documentation of examination and treatment(s) performed or recommended (why it was done and for how long) and physical area(s) treated, vital signs obtained and tests (lab, x-ray, etc.) performed, and the results of each.

g. List start and stop times or total time for each CPT code/service performed on all timed codes per CPT nomenclature.

h. Document the initial diagnosis and the patient’s initial reason for seeking the provider’s care.

i. Document the patient’s current status and progress during the course of treatment provided.

j. Indicate the medications prescribed, dispensed, or administered, and the quantity and strength of each.

k. Include all patient records received from other health care providers if those records formed the basis for treatment decision by the provider.

l. Each entry shall be authenticated by the person making the entry (see Signature Requirements) unless the entire patient record is maintained in the provider’s own handwriting.
m. Each patient record shall include any writing intended to be a final record, but shall not require the maintenance of rough drafts, notes, other writings, or recordings once this information is converted to final form; the final form shall accurately reflect the care and services rendered to the patient.

why post payment audit happening in insurances

POST-PAYMENT AUDITS


BCBSKS conducts periodic post-payment audits of patient records and adjudicated claims to verify congruence with BCBSKS medical and payment policies, including medical necessity and established standards of care. Post-payment audits can range from a basic encounter audit to determine if the level of care is accurately billed, to a complete audit which thoroughly examines all aspects of the medical record and medical practice. Post-payment audits are performed after the service(s) is billed to BCBSKS and payments have been received by the provider. BCBSKS cannot go back further than 15 months following the date of claim adjudication to initiate an audit. Due to additional time allowed for provider appeals, as outlined in this policy memo, refunds would be applicable after the provider appeals have been exhausted, regardless of the time frame involved. BCBSKS provides education through policy memos, medical policy, newsletters, workshops, direct correspondence, peer consultant medical opinion, and on-site visits.


If medical necessity is not supported by the medical record, BCBSKS will deny as not medically necessary. When BCBSKS requests medical records for an audit and no documentation is received within the 30-day time limit, BCBSKS will deny for no documentation. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.


Post-payment Audit Appeals:

A. First-Level Appeal

Services denied not medically necessary as a part of the post-pay audit process may be appealed in writing within 30 days of notification of the findings. Written notification of disagreement highlighting specific points for reconsideration should be provided with the appeal. The BCBSKS determination will be made within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

B. Second-Level Appeal

A provider may request a second and final appeal in writing within 30 days of notification of the first-level appeal determination. The second and final appeal determination will be made by a physician or clinical peer within 30 days of receipt of the appeal. Submit the appeal as instructed in the letter containing the determination.

When findings reveal issues, which are presently specified in BCBSKS policy memos, billing guidelines or newsletters relating to content of service, multiple surgery guidelines, and other billing and/or reimbursement guidelines, the terms of this appeal are not available

NON-COVERED SERVICES

Providers are not reimbursed for professional services they provide to an immediate family member (“immediate family member” means the husband or wife, children, parents, brother, sister, or legal guardian of the person who received the service) or themselves as specified in the member contract.

There are several categories of services, procedures, equipment and/or pharmaceuticals that may be considered non-covered services when designated by the member’s contract. These denials are billable to the member. (

Top Medicare billing tips