Wednesday, April 9, 2014

Can we submit the claim if patient has provided the backdated card , what is the time limit for secondary claims

Backdated Medicaid Cards 

If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card.  Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.  

Example:  Services rendered by a physician on 3/1/2012; on 6/1/2012, member‟s Medicaid eligibility is granted effective 3/1/2012.  All services previously rendered after 3/1/2012 can be billed to Medicaid, and considered for reimbursement if claims are received by 6/1/2013.


MCO‟s and Timely Filing 

Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible.  In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service. Please Note: The MCO must be one of the MCO‟s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.

To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical card.)

The original claim must have had the following valid information:
•   Valid provider number
•   Valid member number
•   Valid date of service
•   Valid type of bill

Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.

This policy is applicable to reversal/replacement claims.  If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing.

Medicare Primary Claims/Secondary Claims 

Timely filing requirement for Medicare primary claims is one year from the EOMB date. Did you know that secondary claims can be submitted electronically? For more information, please call our EDI help desk at 888-483-0793, option 6.

Thursday, April 3, 2014

Billing provider - License updating policy

 License Update Policy 

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) Provider  Enrollment Unit, 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:

•  Sixty (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 removed. 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 and Molina was not able to verify license renewal through the licensing boards. The provider will remain on pay hold until the updated license is sent to Molina.

•  Sixty (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.

•  Ninety (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 rendered by the provider prior to the expiration date will be included in the letter. All other claims will remain voided and not payable.  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 expiration of the current license.  Mailing address: Molina Provider Enrollment, PO Box 625, Charleston, WV 25322.  Fax: Provider Enrollment 304-348-2763.

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

Thursday, March 27, 2014

How much is Medicaid copay - out of pocket and what are the exemption cases

Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid Members. The following copays will apply to claims with a date of service on or after January 1, 2014:

Service TIER 1 Up to 50.00% FPL   TIER 2 50.01-100.00% FPL     TIER 3 100.01% FPL and above 

Inpatient Hospital (Acute Care 11x)  --- $0  $35  $75

Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care)                                ---  $0  $2  $4


Non-Preferred Drugs ----  $2  $4  $8

Non-Emergency use of Emergency Department - Hospital only  (Lowest level (99281) of Emergency Room visits in hospitals.  The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.)  ---------- $8  $8  $8

Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0  $2  $4


Maximum Out of Pocket (OOP): 

Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment.  The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received.  The following table shows the OOP for each tier level.

Tier Level  Out of Pocket Maximum 
1  (Up to 50.00% FPL)  $8
2 (50.01-100.00% FPL)  $71
3 (100.01% FPL and above)  $143

Quarters 
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014

Exemptions: 
The following populations and services are exempt from copays:
  Pregnant Women including pregnancy-related services up to 60 days post-partum;
  Children under age 21;
  Native American and Alaska natives;
  Intermediate Care Facility or MR services;
  Preventive services for children under age 18;
  Provider-preventable services;
  Individuals in Nursing Homes,
  Receiving Hospice services,
  Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
  Family Planning services and Emergency services.  

Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.


Wednesday, March 19, 2014

BCBS insurance id starts with VMB, VMA, XJQ, XJX and VME

How will our office recognize an Exchange member?

Our member identification (ID) cards will not change. However, there will be new alpha prefixes on ID cards for Exchange members:
VMB = Individual HMO
VMA = Individual PPO
XJQ = Small Group HMO
XJX = Small Group
VME/VMD = Individual HMO and PPO off-Exchange

How do I verify member benefits?

You may verify eligibility and benefits for Florida Blue members on the Exchange as you do today for any other Florida Blue member. Providers and/or their designees (billing services, clearinghouses, etc.) should use clinical, financial and administrative electronic self-service capabilities including those accessed through Availity®1. These capabilities include but are not limited to:

Submitting administrative inquiries electronically through Availity using Authorizations and Referrals Review and Inquiry, Eligibility and Benefits, CareCalc®, the Claim Reconciliation Tool and Claims Status.

When using certain Availity transactions (Authorizations and Referrals Review and Inquiry, Eligibility and Benefits Inquiry), providers should use the automated transaction capability and obtain a transaction ID through Availity. Providers will not receive eligibility and benefits information from Florida Blue without a transaction ID. This transaction ID will also provide fast-path priority service if you should need to call the Florida Blue Provider Contact Center for assistance. You may call the Provider Contact Center at (800) 727-2227.

What if a member does not have an ID card or I can’t find eligibility and benefits information in Availity?

If you cannot find member information in Availity, call the Provider Contact Center at (800) 727-2227 for enrollment status or have the member call the number on the back of their ID card. As a reminder, if the member does not have an ID card and does not know their member ID number, you can check eligibility and benefits in Availity by using the member’s name and date of birth.

Will providers who already use electronic transactions have to do anything differently?

No. Providers should continue to follow the same processes in place today.

What is the coverage effective date for members enrolled on the Exchange?

For members who enroll on the Exchange between Oct.1, 2013 – Dec. 23, 2013, the coverage effective date is Jan. 1, 2014.

Exchange open enrollment continues from Dec. 23, 2013 – Mar. 31, 2014.  Applications received prior to the 15th day of the month are effective the first day of the following month. For example, if an application is received on Mar. 10, 2014, the coverage effective date is Apr. 1, 2014.  





Thursday, March 13, 2014

Medicare EOB sequestration payment reduction code CO 253

New Claim Adjustment Reason Code (CARC) to Identify a Reduction in Payment Due to Sequestration 

This article is based on CR 8378 which informs Medicare contractors about a new Claim Adjustment Reason Code (CARC) reported when payments are reduced due to Sequestration. Make sure that your billing staffs are aware of these changes.

As required by law, President Obama issued a sequestration order on March 1, 2013, canceling budgetary resources across the Federal Government. As a result, Medicare Fee-For-Service claims, with dates of service or dates of discharge on or after April 1, 2013, incur a two percent reduction in Medicare payment. The Centers for Medicare & Medicaid services (CMS) previously assigned CARC 223 (Adjustment code for mandated Federal, State or Local law/regulation that is not already covered
by another code and is mandated before a new code can be created) to explain the adjustment in payment.

Effective June 3, 2013, a new CARC was created and will replace CARC 223 on all applicable claims.
The new CARC is as follows:

•  253 - Sequestration - Reduction in Federal Spending

Also, Medicare contractors will not take any action on claims processed prior to implementation of CR8378.


The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.  

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