Monday, July 14, 2014

Filing claim to Medicare after offset from Medicare advantage plan (HMO)

Retroactive Disenrollment from a Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) Provider Organization


There may be situations where a beneficiary is enrolled in an MA plan or in a PACE provider organization, and later becomes disenrolled from the MA plan or PACE provider organization. And, if the MA plan or the PACE provider organization recoups the money it paid the provider or supplier 6 months or more after the service was furnished, the provider or supplier may be granted an exception to have those claims filed with Medicare.

In order to qualify for this exception, the provider or supplier will need to provide the claims processing contractor with information that verifies:
• prior enrollment of the beneficiary in an MA plan or PACE provider organization;
• the beneficiary, the provider, or supplier was notified that the beneficiary is no longer enrolled in the MA plan or PACE provider organization;
• the effective date of the disenrollment; and,
• the MA plan or PACE provider organization recouped money from the provider or supplier for services furnished to a disenrolled beneficiary.

If the contractor determines that all of the conditions described above are satisfied, the contractor will notify the provider or supplier in writing that a filing extension will be allowed from the end of the 6th calendar month from the month in which the MA plan or PACE provider organization recouped its money from the provider or supplier.

The time for filing a claim will be extended if CMS or one of its contractors determines that a failure to meet the filing deadline is caused by all of the following conditions:

(a) At the time the service was furnished the beneficiary was enrolled in a Medicare Advantage (MA) plan or Program of All-inclusive Care for the Elderly (PACE) provider organization.
(b) The beneficiary was subsequently disenrolled from the Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization effective retroactively to or before the date of the furnished service.
(c) The Medicare Advantage plan or Program of All-inclusive Care for the Elderly (PACE) provider organization recovered its payment for the furnished service from a provider or supplier 6 months or more after the service was furnished.

Wednesday, July 9, 2014

How to report multiple NDC code - and format

NDC Billing Instructions 

Molina EDI Help Desk reports that claims are being rejected because more than one NDC code is being billed on one service line.  Below you will find instructions on billing multiple NDC codes for the same drug on a claim.  

For  more  detailed  information  on  billing  NDC  codes,  please  see  the  BMS  website  at
www.dhhr.wv.gov/bms under the heading “HCPCS/Drug Codes”.  

NDC’s must be configured in what is referred to as a 542 format.  The first segment must include five digits, the second segment must include four digits, and the third segment must include 2 digits.  If an NDC is missing a number on the product label, the appropriate number of zeros must be added at the beginning of the segment.  Only the NDC as specified on the label of the product that is administered to the member is to be billed.  Every NDC must be billed with an N4 qualifier before the NDC with no hyphens or spaces, the unit qualifier such as F2 (International Unit), GR (Gram), ML (Milliliter), and UN (Unit) and the NDC quantity.  Billing instructions are available at www.dhhr.wv.gov/bms & Molina Medicaid Solutions at www.wvmmis.com. Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Important: All NDC charges must have the specific date of service the listed drug was adminis-tered and all NDC drug charges must be listed individually.

Multiple NDCs 

At times, it may be necessary for providers to report multiple NDCs for a single procedure code.  For codes that involve multiple NDCs (other than compounds, see BMS website), providers must bill the procedure code with KP modifier and the corresponding procedure code NDC qualifier, NDC, NDC unit qualifier, and NDC units.  The claim line must be billed with the charge for the amount of the drug dispensed for the NDC identified on the line.  The second line item with the
same procedure code must be billed utilizing KQ modifier, the procedure code units, charge and NDC information for this portion of the drug.

Prevnar Immunization 

Effective 12/30/2011 Prevnar 13® is available for WV Medicaid members over the age of 50. Prevnar 13® is FDA approved for adults 50+ years of age to help prevent pneumococcal pneu-monia, meningitis, and bacteremia caused by 13 strains of S pneumonia. CPT code 90670 is to be billed for adult vaccinations; the reimbursement includes the cost of administration – the im-munization administration codes are not to be billed separately for adult vaccines. Prevnar 13® is currently available for children up to the age of 6 through the Vaccines for Chil-dren (VFC) Program.  As with all VFC vaccines, bill the administration code with your charge for the service and the vaccine code with the SL modifier to indicate the vaccine was provided under
the VFC Program at no cost.

Friday, June 27, 2014

Medicare incarceration recoupment and appeal option

RECOUPMENTS 

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue? 

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest? 

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction? 

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid? 

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim? 

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

RECOUPMENTS

Q1: Do suppliers and providers need to take any steps to be repaid for incorrect recoupments resulting from this issue?

A1: Supplier claims will be reprocessed and refunds issued by the end of the first week of December 2013. The majority of non-supplier provider claim refunds will be made by the middle of December. Last updated 11-27-13

Q2: Will Medicare repay the recoupments with interest?

A: The Medicare statute only permits CMS to pay interest under limited circumstances, and this situation does not trigger the payment of interest to providers and suppliers. Last updated 11-27-13

Q3: What happens to corrections of recoupments that occur after a new MAC has taken over a jurisdiction?

A3: All claims and accounts receivables have been transferred to the incoming MAC.
Last updated 11-20-13

Q4: If a provider or supplier paid interest on one of the collected overpayments, will the repayment of that claim include the amount of interest the provider or supplier paid?

A4: Yes, the provider or supplier will receive a refund for the amount paid including any interest paid.


I continue to receive demand letters and the MAC continues to recoup money for an incarcerated beneficiary related overpayment. What should I do?

A5: While CMS previously zeroed out most of the incarcerated beneficiary overpayments, due to changes in our records over the years, we are still working to identify, zero out, and process refunds for some of the erroneous overpayments. If you are aware of an incarcerated beneficiary overpayment that is still being collected, you should bring it to the attention of your MAC as soon as possible.

APPEALS

Q1: Can I appeal the denied claim? Who is liable for the denied claim?

A1: Yes, providers, suppliers, and beneficiaries can appeal the denied claims. Liability for the denied claims will be determined for each claim on a case by case basis.
Last updated 11-20-13

Q2: Once CMS reprocesses the inappropriate claim denials/cancellations, will there be a way for providers to appeal denied claims that were deemed appropriate even if the time limits for filing appeals expired?

A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.
A2: The Medicare Administrative Contractors have been instructed to accept appeal requests for claim denials or overpayments related to incarcerated beneficiaries without regard to the time limits for filing appeals.

Thursday, June 19, 2014

Medicare incarcerated denial - all question and time frame solution

BACKGROUND

Medicare will generally not pay for medical items and services furnished to a beneficiary who was incarcerated or in custody under a penal statute or rule at the time items and services were furnished. For additional information about this policy, please refer to the Medicare Learning Network’s recent “Medicare Coverage of Items and Services Furnished to Beneficiaries in Custody Under a Penal Authority” Fact Sheet (ICD 908084).

Recently, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated or in custody on the date of service. For these recoveries, CMS identified previously paid claims that contained a date of service that partially or fully overlaps a period when a beneficiary was apparently incarcerated based on information from the Social Security Administration (SSA). As a result, a number of overpayments were identified. In some cases demand letters were released with appeals instructions, and, in many cases, automatic collections of overpayments were made. However, CMS has since learned that the information
was, in some cases, incomplete for purposes of collection.

CMS understands that this issue has been challenging for providers and beneficiaries, and we are actively addressing it. We have restored the original data on the Medicare Enrollment Data Base. Any new claims that are denied on or after October 28, 2013, because the beneficiary was incarcerated on the date of service, are based upon that information. We are also identifying all of the claims that were incorrectly demanded or collected, making changes to claims processing systems, and refunding amounts collected. This process will identify the claims that were denied in error and reprocessing will be completed by the Medicare Administrative Contractors.


RESOLUTION TIMEFRAME AND PROCESS 

Q1: How is CMS resolving the claims denial issues associated with the June, July, and August 2013 incarcerated beneficiaries’ data? 

A1: The resolution of this situation requires a series of complex actions, including the restoration of the original data on the Medicare Enrollment Data Base (EDB), the identification of claims that were incorrectly denied or cancelled, the determination of amounts that will need to be refunded, and making changes to our claims processing systems to update Medicare history and notify the other users of our data, such as secondary insurers. The EDB data has been updated and CMS has reduced related non-supplier open accounts receivable to zero in the majority of instances. Most suppliers will receive refunds by the first week in December.

Refunds for non-supplier providers will begin to be issued during the first week in December and the majority should be issued by the middle of December. Note that accounts receivable related to claims that have been appealed are not impacted by this action; appealed claims will be handled separately and, where appropriate, refunds will be generated at a later date.

Q2: As part of the reprocessing work to correct the erroneous claim denials, is Medicare reviewing the claims that were denied on a daily basis between CWF updates during June, July, and August 2013? 

A2: Yes. Now that the up-to-date incarcerated beneficiary data from the Social Security Administration has been loaded into its systems, CMS has instructed its Medicare Administrative Contractors (MACs) to reprocess any claims that may have been denied on or after May 1, 2013 through October 28, 2013, to ensure that the denial was correct. If the original denial was in error, the MAC will adjust the claim to pay. All of the reprocessing should be completed no later than the end of December 2013.

Q3: Were providers notified of which accounts receivable were closed? 

A3: No.


Q4: Were all of the accounts receivable associated with the erroneous claim denials/cancellations closed? 


No. Most of the accounts receivable for erroneous provider claims denials/cancellations were closed. However any accounts receivables in an appeal, bankruptcy, fraud or CMS hold status were not closed. Finally, a group of accounts receivable for affected professional provider claims that haven’t been closed will be closed by the Medicare Administrative Contractor. The timeframe for this activity is not yet finalized.
Last updated 11-27-13

Q5: If an accounts receivable was not closed, does that mean that the overpayment is valid and will be pursued using normal procedures? 

A5: If an accounts receivable was not closed and does not fall into one of these groups, appeal, bankruptcy, fraud or CMS hold status, the providers and suppliers should assume that the overpayment is valid and it will be recouped using normal procedures.



Q6: Will the overpayment letters/demand letters that went out for the claims that were subsequently reprocessed be rescinded? 
A6: No. This action is not necessary because the Accounts Receivable was closed if the demand was not paid, or refunded if the demand was paid.



Friday, June 13, 2014

Frequency of Billing for Providers Submitting Institutional Claims with Outpatient Services


Repetitive Part B services furnished to a single individual by providers that bill institutional claims shall be billed monthly (or at the conclusion of treatment). The instructions in this subsection also apply to hospice services billed under Part A, though they do not apply to home health services. Consolidating repetitive services into a single monthly claim reduces CMS processing costs for relatively small claims and in instances where bills are held for monthly review. Services repeated over a span of time and billed with the following revenue codes are defined as repetitive services:

Type of Service  Revenue Code(s)
DME Rental 0290 – 0299
Respiratory Therapy 0410, 0412, 0419
Physical Therapy 0420 – 0429
Occupational Therapy 0430 – 0439
Speech-Language Pathology 0440 – 0449
Skilled Nursing 0550 – 0559
Kidney Dialysis Treatments 0820 – 0859
Cardiac Rehabilitation Services 0482, 0943


Hospitals in Maryland that are under the jurisdiction of the Health Services Cost Review Commission are subject to monthly billing cycles.

Where there is an inpatient stay, or outpatient surgery, or outpatient hospital services subject to OPPS, during a period of repetitive outpatient services, one bill for repetitive services shall nonetheless be submitted for the entire month as long as the provider uses an occurrence span code 74 on the monthly repetitive bill to encompass the inpatient stay, day of outpatient surgery, or outpatient hospital services subject to OPPS. CWF and shared systems must read occurrence span 74 and recognize the beneficiary cannot receive non-repetitive services while receiving repetitive services, and consequently, is on leave of absence from the repetitive services. This permits submitting a single, monthly bill for repetitive services and simplifies Contractor review of these bills.

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