EqualityCare EqualityCare · • EqualityCare/Medicaid – Long term care – Aged/blind/disabled...

EqualityCare EqualityCare EqualityCare EqualityCare General Provider manual

• EqualityCare/Medicaid– Long term care – Aged/blind/disabled (SSI) – Family care – Presumptive eligibility for

pregnant women – Qualified Medicare

Beneficiary (QMB) – Special Low Income

Medicare Beneficiary (SLIMB)

• EqualityCare For Children • State Foster Care • Children’s Special Health

(CSH) – High Risk Maternal

(HRM) – Newborn Intensive Care

(NBIC)

• EqualityCare HCBS – Long Term Care Waiver

(LTC) – Adult Developmental

Disability (DD) Waiver– Children’s

Developmental Disability (DD) Waiver

– Acquired Brain Injury (ABI) Waiver

– Assisted Living (ALF) Waiver

• Prescription Drug Assistance Program (PDAP)

• Marginal Dental Program • AIDS Drug Assistance

Program (ADAP) • State Licensed Shelter Care • Employed Disabled

Individual Program (EDI)

General Provider Information August 2003

AUTHORITY

The Wyoming Department of Health is the single State agency appointed pursuant to the Social Security Act to administer the Medicaid program in Wyoming. The Office of Medicaid directly administers the EqualityCare/Medicaid program in accordance with the Social Security Act, the Wyoming Medical Assistance and Services Act, (W.S. 42-4-101 et seq.), and the Wyoming Administrative Procedures Act (W.S. 16-3-101 et seq.) This manual is intended to be a guide for the provider when filing medical claims with the EqualityCare programs. The manual is to be read and interpreted in conjunction with Federal regulations, State statutes, administrative procedures and Federally approved State Plan and approved amendments. This manual does not take precedence over Federal regulation, State statutes or administrative procedures.


Table of Contents General Provider Manual

Chapter One - General Information

How the Billing Manual is Organized ................................................................................... 1-2 Updating the Manual and Billing Modules............................................................................ 1-3 State Agency Responsibilities................................................................................................ 1-3 Fiscal Agent Responsibilities................................................................................................. 1-3 Chapter Two - Getting Help When You Need It How to Call for Help.............................................................................................................. 2-2 How to Write for Help ........................................................................................................... 2-2 How to Get On-Site Help....................................................................................................... 2-2 How to Get Help Online ........................................................................................................ 2-2 Ordering Claim Forms ........................................................................................................... 2-4 Training Workshops............................................................................................................... 2-4 Quick Address and Telephone Reference.............................................................................. 2-5 Provider Inquiry Form ........................................................................................................... 2-7 Claim Order Form.................................................................................................................. 2-8

Chapter Three - Provider Responsibilities Enrollment.............................................................................................................................. 3-2

Changes in Enrollment............................................................................................... 3-2 Re-certification .......................................................................................................... 3-2 Termination................................................................................................................ 3-3

Accepting EqualityCare Patients............................................................................................. 3-3 Compliance Requirements ......................................................................................... 3-3 Provider-Patient Relationship .................................................................................... 3-3

Medical Necessity.................................................................................................................. 3-4 EqualityCare Payment is Payment in Full .............................................................................. 3-5 Out-of-State Service Limitations ........................................................................................... 3-5

Medicare Covered Services ....................................................................................... 3-6 Usual and Customary Charges............................................................................................... 3-7 Record Keeping, Retention, and Access................................................................................ 3-7

Requirement............................................................................................................... 3-7 Retention of Records.................................................................................................. 3-7 Access to Records ...................................................................................................... 3-7 Audits and On-Site Visits .......................................................................................... 3-8

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Chapter Four - Utilization Review Utilization Review ................................................................................................................. 4-2

Complaint Referral..................................................................................................... 4-2 Release of Medical Records....................................................................................... 4-2 Client Lock-In............................................................................................................ 4-2

Fraud and Abuse .................................................................................................................... 4-3 Definition of Fraud .................................................................................................... 4-3 Definition of Abuse.................................................................................................... 4-3 Provider Responsibility.............................................................................................. 4-3 Referral of Suspected Fraud and Abuse..................................................................... 4-4

Sanctions .................................................................................................................... 4-4 Adverse Action .......................................................................................................... 4-4

Report of Suspected Abuse of the EqualityCare Health Care System........................ 4-5

Chapter Five - Electronic Media Claims What is Electronic Media Claims (EMC) Submission? ........................................................ 5-2 Getting Started in EMC ......................................................................................................... 5-2 The Future in Medicaid Claims Processing ............................................................... 5-2 Benefits ...................................................................................................................... 5-2 Requirements ............................................................................................................. 5-2 Submission Methods............................................................................................................. 5-3 Chapter Six - Verifying Client Eligibility

What is EqualityCare .............................................................................................................. 6-2 Who is Eligible?..................................................................................................................... 6-3 Eligibility Determination ....................................................................................................... 6-4

Responsible Agency................................................................................................... 6-4 Services Available ................................................................................................................. 6-4 Limitations ............................................................................................................................. 6-7 Definition of Plans ................................................................................................................. 6-8 Client Identification Cards................................................................................................... 6-10

Other Types of Eligibility Identification.................................................................. 6-10 Presumptive Eligibility ............................................................................................ 6-10

Clients Without Cards.......................................................................................................... 6-10 Responsibility for Provider Payment ................................................................................... 6-10 Medicare Eligibility ............................................................................................................. 6-11

Description of Medicare Benefits ............................................................................ 6-11 Services Provided in Wyoming ............................................................................... 6-11

Client Lock-In...................................................................................................................... 6-11 Freedom of Choice............................................................................................................... 6-12 Verification of Client Eligibility.......................................................................................... 6-12 Client Identification ............................................................................................................. 6-12 Verification of Client Age ................................................................................................... 6-12 Verification Options............................................................................................................. 6-13

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Automated Voice Response (AVR)..................................................................................... 6-14 Provider Terminal Network ................................................................................................. 6-14 Assistance to Potential Eligibles.......................................................................................... 6-15 Presumptive Eligibility ........................................................................................................ 6-16 Chapter Seven - Common Billing Information Where to Send Your Claim......................................................................................................7-2 Authorized Signatures..............................................................................................................7-2 Cap Limit Waivers...................................................................................................................7-2 How to Bill for Newborns........................................................................................................7-3 No Show Appointments...........................................................................................................7-3 Medicare Crossovers................................................................................................................7-3 General Information.....................................................................................................7-3 How to File a Claim for a Dually Eligible Client ........................................................7-3 Prior Authorization ..................................................................................................................7-4 How to Complete the Prior Authorization Form .......................................................7-7 Required Attachments and How to Complete .........................................................................7-9 Attachments ...............................................................................................................7-10 Consent Forms .......................................................................................................................7-11

Sterilization Consent Form ........................................................................................7-13 Hysterectomy Acknowledgment of Consent .............................................................7-15 Abortion Certification................................................................................................7-17

The Remittance Advice (RA) ................................................................................................7-18 When Your Patient Has Other Insurance...................................................................7-19

Sample Remittance Advices ......................................................................................7-20 How to Read Your Remittance Advice .....................................................................7-24 How to Resubmit a Denied Claim .........................................................................................7-26 Adjustments and Refunds ......................................................................................................7-26 Refunding Money to EqualityCare ............................................................................7-26 Incorrectly Billed or Keyed Claims ...........................................................................7-27 Third Party Recovery After EqualityCare’s Payment.................................................7-27 How to File a Void or Adjustment Request...............................................................7-27 How to Complete the Adjustment Request Form......................................................7-29 Timely Filing .........................................................................................................................7-30

Timely Filing Criteria ................................................................................................7-30 Exceptions to the Twelve Month Limit .....................................................................7-30 Appeal of Timely Filing.............................................................................................7-30 Important Information Regarding Retroactive Eligibility Decisions.........................7-31 Failure of Eligible Client to Notify Provider of EqualityCare Eligibility...................7-31 Billing Tips to Avoid Timely Filing Denials.............................................................7-31 Filing Deadlines for Adjustments ............................................................................. 7-32

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Chapter Eight - Third Party Liability What Is Third Party Liability (TPL)? .................................................................................... 8-2 How To Identify TPL............................................................................................................. 8-2 How to Bill Third Party Payers ............................................................................................. 8-3 What are the exceptions to Third Party Billing? ................................................................... 8-4

When the services are for Preventive Pediatric Care................................................. 8-4 When the services are related to Prenatal Care.......................................................... 8-4 When the policy holder of the other insurance is an absent parent ........................... 8-4 When legal liability has not been established ............................................................ 8-5

Questions about TPL ............................................................................................................. 8-5 Why should I care about TPL? .................................................................................. 8-5 Who pays the bill when a client has other insurance? ............................................... 8-5 Can I refuse to accept EqualityCare patients with other insurance if my

Office doesn't bill other insurance? ................................................................ 8-6 When can I bill a client? ............................................................................................ 8-6

Wyoming Health Insurance Premium Payment Program...................................................... 8-7 What is WHIPP? ....................................................................................................... 8-7 Benefits to clients ...................................................................................................... 8-7 Benefits for all Wyoming residents ........................................................................... 8-7 What will EqualityCare cover under the WHIPP program? ...................................... 8-7 What clients must do to enroll in WHIPP? ............................................................... 8-8

Previous Billing Attempts Letter ........................................................................................... 8-9 Third Party Resources Information Sheet............................................................................ 8-10 Health Insurance Verification Form .................................................................................... 8-11 WY Health Insurance Premium Payment Statement ........................................................... 8-12 Health Insurance Premium Payment Medical History Questionnaire ................................. 8-13 Chapter Nine – HIPAA Introduction HIPAA Introduction............................................................................................................... 9-2 Implementation Dates ............................................................................................................ 9-3 Claims Submission................................................................................................................. 9-3 Glossary of HIPAA Transactions .......................................................................................... 9-4 Submitting Claims Electronically .......................................................................................... 9-4 Pharmacies and HIPAA ......................................................................................................... 9-5 Number of Lines .................................................................................................................... 9-5 Prior Authorization ................................................................................................................ 9-5 Paper Attachments ................................................................................................................. 9-6 Nursing Facility Claims ......................................................................................................... 9-6 Local Codes and Modifiers.................................................................................................... 9-6 Adjustments ........................................................................................................................... 9-6 Remittance Advices ............................................................................................................... 9-6 Checking Status of a Claim.................................................................................................... 9-7 Checking Client Eligibility .................................................................................................... 9-7 Additional Information Sources............................................................................................. 9-8

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Chapter One General Information

How the Billing Manual is Organized.................................................................................. 1-2 Updating the Manual and Billing Modules .......................................................................... 1-3 State Agency Responsibilities .............................................................................................. 1-3 Fiscal Agent Responsibilities ............................................................................................... 1-3

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EqualityCare is the name chosen by the Wyoming Department of Health for the State’s public health insurance plans. This name reflects our state’s great history as the “Equality State” as well as promoting equality in health care benefits and services. The separate programs themselves (such as CSH, EqualityCare for Children, etc.) have not changed. The billing information for other programs (like the DD Waiver Services, Long Term Care, etc.) is still contained within the manual and modules. Medicaid has not gone away, it is part of the larger whole. The manuals have been reformatted to go along with this change as well as updating the information presented. In this spirit, this manual will now refer to the Wyoming public health care programs as simply “EqualityCare”.

How the EqualityCare Billing Manuals are Organized

The manuals are designed to give you the tools you need to bill EqualityCare for services rendered to eligible clients. General information including client eligibility, provider responsibilities, and common billing information are included in the General Provider Manual. Specific billing instructions, covered services and limitations are included in the modules that you receive with your General Manual. A quick reference guide for this General Manual is provided below:

Chapter Description

Two Getting Help When You Need It tells you when and how to order claims and other forms. Telephone numbers and addresses for help and training are also included.

Three

Provider Responsibilities explains your obligations and rights as an EqualityCare provider. The topics covered include enrollment changes, civil rights, group practices, provider-patient relationship, and record keeping requirements.

Four

Utilization Review defines fraud and abuse, explains the review process, and tells you about your rights and responsibilities for adhering to these.

Five

Electronic Media Claims tells you about the benefits of submitting your claims electronically and how to get started in EMC.

Six

Verifying Client Eligibility tells you how to get eligibility information when a client presents their EqualityCare card to you. This chapter also addresses eligibility determination, verification of client data and Medicare eligibility. It tells you how to determine if EqualityCare will pay for the service you intend to provide.

Seven

Common Billing Information briefly explains how the payment system works and what you should do when ACS, Inc. responds to your claim. Your claim must be complete, accurate and for a covered service provided to an eligible client before EqualityCare can consider payment. This chapter includes Prior Authorization and consent forms.

Eight

Third Party Liability (TPL) tells you what TPL is, how to bill TPL, exceptions to TPL, and answers to questions about TPL. This chapter also explains the Wyoming Health Insurance Premium Program and what forms are necessary for this program.

Nine HIPAA defines HIPAA and explains the specific changes that occur for providers.

Appendices Appendices provide you with necessary information in an at-a-glance format. These include SSA district office information, DFS offices, WMSA and out-of-state codes and other pertinent information.

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Updating the Manual and Billing Modules

When there is a change in the EqualityCare programs that affect you, ACS, Inc. will send you a printed update to the manual. It is your responsibility to update your manual by replacing existing pages with these revisions. If you believe you may have missed an update, call the Provider Relations Unit at (307) 772-8401 locally or outside Cheyenne at 1-800-251-1268 and request a copy of the missing update.

State Agency Responsibilities

The Office of Medicaid administers the EqualityCare/Medicaid program for the Department of Health. It is responsible for financial management, developing policy, establishing benefit limitations, payment methodologies and fees, and performing utilization review.

Fiscal Agent Responsibilities

ACS, Inc. is the fiscal agent for EqualityCare. ACS processes claims and adjustments. They also answer provider inquiries regarding claim status, payments, client inquiries and third party liability information. ACS provides on-site visits to train your office staff on EqualityCare billing procedures or to resolve claims payment issues. In conjunction with The Office of Medicaid, ACS, Inc. conducts provider workshops for your staff on an annual basis regarding billing and policy procedures.

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Chapter Two Getting Help When You Need It

How to Call for Help................................................................................................................2-2 How to Write for Help .............................................................................................................2-2 How to Get On-Site Help.........................................................................................................2-2 How to Get Help Online ..........................................................................................................2-2 Ordering Claim Forms .............................................................................................................2-4 Training Workshops.................................................................................................................2-4 Quick Address and Telephone Reference................................................................................2-5 Provider Inquiry Form .............................................................................................................2-7 Claim Order Form....................................................................................................................2-8

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How to Call for Help

ACS, Inc. maintains a well-trained Provider Relations Unit that is dedicated to assisting you. These individuals are prepared to answer inquiries regarding client eligibility, service limits, third party coverage, and provider payment issues. Inquiry telephone lines are open Monday through Friday, 9 a.m. to 5 p.m. (307) 772-8401 locally or 1-800-251-1268 outside Cheyenne. How to Write for Help

In many cases, writing for help provides you with more detailed information about your clients. In addition, the written responses can be kept as permanent records for future reference. To expedite the handling of written inquiries, we recommend that you use a Provider Inquiry Form (Exhibit 2.1). You may copy the form in this handbook or call or write for original forms. (See ordering claim forms below.) Mail completed form to:

ACS, Inc. Provider Relations Unit

P. O. Box 667 Cheyenne, WY 82003

ACS, Inc. will mail a response to your inquiry to you within ten working days of receipt.

How to Get On-Site Help

ACS, Inc. Provider Field Representatives are available to make on-site visits to train your office staff on EqualityCare billing procedures or to resolve claims payment issues. For assistance call: (307) 772-8401 or 1-800-251-1268 outside Cheyenne.

How to Get Help Online

The website address for EqualityCare is http://wyequalitycare.acs-inc.com/T. Through this site, you can access provider manuals, bulletins and fee schedules. Non-secure information will be available without the 128-bit encryption capabilities. You will not have to register to view:

• EqualityCare publications such as provider manuals and bulletins; • Forms for download – claim forms, prior authorization requests, etc.; • Answers to your frequently asked EqualityCare questions. Providers can apply for access to the secure Provider Services section by filling out

An online New User Registration application. Once the application is completed and the provider’s User Id and password are registered, ACS, Inc. will send confirmation e-mail to that provider. Once registered, the following Provider Services will be available:

Online retrieval of recent Remittance Advices Web-based entry of requests to update provider file information Management of an organization’s users via the site’s User Administration area

NOTE: The person completing the initial registration will be designated as the organization’s

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http://wyequalitycare.acs-inc.com/


User Administrator. The User Administrator has the authority to add and delete users having access to the organizations information through the website. If you do not wish to be the User Administrator, the appropriate person within your organization should complete the enrollment process.

The website provides links to allow you to access client eligibility information via Medifax or eligibility information and claims history through MEVSNET. (See Chapter Six for further information on how to use Medifax and MEVSNET.) Contact your vendor for further information on how you can receive these services through the internet. Encryption of this site has been enhanced to 128-bit, which is also known as “strong”, “domestic”, and /or “U.S.” encryption. In order to support this, you will need to use one of the following browsers:

• Microsoft Internet Explorer 5.x with 128-bit encryption • Microsoft Internet Explorer 4.x with 128-bit encryption • Netscape Navigator 6.0 with 128-bit encryption • Netscape Navigator 4.08 with 128-bit encryption • America On Line 6.0 with 128-bit encryption • America On Line 5 or higher with 128-bit encryption • America On Line 4 or higher with 128-bit encryption • America On Line 3 – using a standalone version 4 or above browser

The website furnishes information on how to upgrade your browser.

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Ordering Claim Forms

Before ordering new forms, continue to use any invoices presently on hand until your supply is nearly exhausted (down to a two-week supply). ACS, Inc. supplies the following forms free of charge:

• Abortion Certification • Adjustment Request • Assisted Living Facility Waiver Plan of Care Form • Claim Order Form • Compound Prescription • Documentation of Medical Necessity • Health Check Referral Form • LTC Waiver Plan of Care Form • LTC Consumer-Directed Plan of Care Form • Hysterectomy Consent • LT101 Assessment of Medical Necessity • LT-MR-104 • Paper Claim And/Or PA Attachment Control Document • PASRR Level I • Presumptive Eligibility Application and Benefit Form • Prior Authorization • Provider Inquiry • Sterilization Consent • Third Party Resources Information

Order Form

Contact ACS, Inc. for an order form or make a copy of Exhibit 2.2 in this manual. Send your request to the following address and allow two weeks for delivery:

ACS, Inc. P. O. Box 667

Cheyenne, WY 82003

Training Workshops

ACS, Inc., in conjunction with EqualityCare, conducts provider workshops for your staff regarding billing and policy procedures on an annual basis. You will receive advance notice of these workshops through a provider bulletin. ACS, Inc. and EqualityCare sponsor training seminars at selected in-state and out-of-state locations. You will receive advance notice of this training through provider bulletins. These annual training sessions allow you direct contact with EqualityCare program staff as well as fiscal agent staff.

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Quick Address and Telephone Reference

For provider inquiries regarding claims, call or write:

ACS, Inc.’s Provider Relations Unit P.O. Box 667 Cheyenne, WY 82003-0667 Local (307) 772-8401 Outside Cheyenne 1-800-251-1268 Fax (307) 772-8405 Pharmacy claim questions 1-800-365-4944 Pharmacy PA questions 1-866-556-9320

Mail claims to:

ACS, Inc./Claims P. O. Box 547 Cheyenne, WY 82003-0547

For provider inquiries regarding client eligibility, call:

Automated Voice Response (Use client ID number or Social Security Number to access) Local (307) 772-8403 Outside Cheyenne 1-800-251-1270 Fax: (307) 772-8405

ACS, Inc.'s Provider Relations Unit Local (307) 772-8401 Outside Cheyenne 1-800-251-1268 Fax (307) 772-8405

For provider inquiries regarding WINASAP 2003, call:

Technical Support for WINASAP 2003 Users Florida ACS EDI Gateway, Inc. 1-800-672-4959 Technical Support for Vendors, Billing Agents and Clearing Houses Florida ACS EDI Gateway, Inc. 1-850-201-1171

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For provider inquiries regarding workshop information or to request a Provider Field Representative visit, call or write:

ACS, Inc. Provider Relations Unit P.O. Box 667 Cheyenne, WY 82003-0667 Local (307) 772-8401 Outside Cheyenne 1-800-251-1268 Fax (307) 772-8405

For policy concerns or suggestions call or write:

Office of Medicaid 147 Hathaway Building 2300 Capitol Avenue Cheyenne, WY 82002 (307) 777-7531

EXHIBIT 2.1

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Provider Inquiry Form

2. EqualityCare Provider Number

3. Telephone Number

1. Provider Name and Address

4. Person to contact in Provider's Office

5. Date of Inquiry

1 6. Client Name: Last, First MI.

7. EqualityCare ID Number

8. Dates of Service

9. Proc. Code

10. Charge

11. RA Date 12. MED Record Number

13. Transaction Control Number

14. Nature of Inquiry 15. ACS, Inc.'s Response 2 6. Client Name: Last, First, MI.

7. EqualityCare ID Number

8. Dates of Service

9. Proc. Code

10. Charge

11. RA Date 12. MED Record Number

13. Transaction Control Number

14. Nature of Inquiry 15. ACS, Inc.'s Response

Mail completed form to:

ACS, INC. PO BOX 667

CHEYENNE, WY 82003-0667

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EXHIBIT 2.2 Claim Order Form

PLEASE ENTER THE QUANTITY DESIRED FOR EACH CLAIM ASSISTED LIVING FACILITY

WAIVER PLAN OF CARE _______ DOC OF MEDICAL NECESSITY _______ HEALTH CHECK REFERRAL FORM _______ HYSTERECTOMY CONSENT _______ LT101 SCREENING FORM _______ LT-MR-104 _______ LT – ABI – 105 _______ PAPER CLAIM/PA ATTACHMENT _______ CONTROL DOCUMENT

PASARR LEVEL 1 _______ P.E. APPLICATION _______ OFFICE OF MEDICAID PE-1 _______ PRIOR AUTHORIZATION _______ PROVIDER INQUIRY FORM _______ STERILIZATION CONSENT _______ TPL RESOURCES INFO SHEET _______ LTC/HCBS WAIVER CARE PLAN _______ CONSUMER DIRECTED WAIVER CARE PLAN _______

PLEASE TYPE OR PRINT YOUR NAME AND ADDRESS ON THE LABEL BELOW. IT WILL BE USED TO SHIP YOUR FORMS.

FROM: ACS

P.O. BOX 547 CHEYENNE, WY 82003-0547

TO: _____________________________________ _____________________________________ _____________________________________


Chapter Three Provider Responsibilities

Enrollment ............................................................................................................................ 3-2

Changes in Enrollment ............................................................................................. 3-2 Re-certification......................................................................................................... 3-2 Termination .............................................................................................................. 3-3

Accepting EqualityCare Patients ........................................................................................... 3-3 Compliance Requirements ....................................................................................... 3-3 Provider-Patient Relationship .................................................................................. 3-3

Medical Necessity ................................................................................................................ 3-4 EqualityCare Payment is Payment in Full ............................................................................. 3-5 Out-of-State Service Limitations.......................................................................................... 3-5

Medicare Covered Services...................................................................................... 3-6 Usual and Customary Charges ............................................................................................. 3-7 Record Keeping, Retention, and Access .............................................................................. 3-7

Requirement ............................................................................................................. 3-7 Retention of Records ................................................................................................ 3-7 Access to Records .................................................................................................... 3-7 Audits and On-Site Visits......................................................................................... 3-8

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General Provider Information August 2003 Enrollment

EqualityCare payment is made only to providers who are actively enrolled in the EqualityCare programs. To be enrolled you must complete and sign an enrollment form and an agreement form. In addition, certain providers are required to submit proof of licensure and/or certification. This requirement applies to both in-state and out-of-state providers. To apply for participation in the EqualityCare programs, call or write to:

ACS, Inc. Provider Enrollment Unit

P. O. Box 667 Cheyenne, WY 82003-0667

1-800-251-1268 outside Cheyenne area or 772-8401 locally

The enrollment is also available on the ACS Website: http://wyequalitycare.acs-inc.com After your application is approved, ACS, Inc. will send you an approval letter containing an EqualityCare provider number and a general provider manual, a covered services manual, and a billing manual. You must use this provider number to bill the EqualityCare programs. If your application is not approved, the notice includes the reasons for the decision and if additional information is needed. No medical provider is declared ineligible to participate in the EqualityCare programs without prior notice. Changes in Enrollment

If any information you listed on your original enrollment application subsequently changes, you must notify ACS, Inc. in writing. You may also make enrollment changes through the ACS website listed above. Examples include, but are not limited to: change of address, change of tax identification number, cessation of practice, and lapse of license, change of ownership or partnership. Send enrollment changes to:

ACS, Inc. Provider Enrollment Unit

P. O. Box 667 Cheyenne, WY 82003

http://wyequalitycare.acs-inc.com Re-certification

Annually ACS, Inc. sends out of state providers a letter requesting a copy of your license or other certifications. If these documents are not submitted within sixty days of their expiration date, you are terminated as an EqualityCare provider. Termination

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You can terminate participation in the EqualityCare programs at any time. Thirty days written notice of voluntary termination is requested. Notices should be addressed to ACS, Inc.

Accepting EqualityCare Patients Compliance Requirements

All providers of care and suppliers of services who participate in the EqualityCare programs must comply with the requirements of Title VI of the Civil Rights Act of 1964, which requires that services be furnished to clients without regard to race, color, or national origin. Section 504 of the Rehabilitation Act provides that no handicapped individual shall, solely by reason of the handicap:

• Be excluded from participation; • Be denied the benefits; or • Be subjected to discrimination under any program or activity receiving federal assistance.

Each EqualityCare provider, as a condition of participation, is responsible for making provision for such handicapped individuals in their program activities. As an agent of the Federal government in the distribution of funds, the Office of Medicaid is responsible for monitoring the compliance of individual providers and, in the event a discrimination complaint is lodged, is required to provide the Office of Civil Rights (OCR) with any evidence regarding compliance with these requirements. Provider-Patient Relationship

The relationship established between the client and the provider of services is both a medical and a financial one. If a client presents himself/herself as an EqualityCare client, you must determine whether you are willing to accept the client as an EqualityCare patient before treatment is rendered. If a client's financial status is unknown, it is your responsibility to determine his/her financial resources and arrange for payment of services. If the client is insured, you must submit a Third Party Resources Information Sheet to ACS, Inc.'s Third Party Liability Unit. If you fail to fulfill this responsibility and the individual is eligible for EqualityCare, it is assumed that you will accept EqualityCare payment. You may not discriminate based on whether or not a client is insured. Once this agreement has been reached, all services you render to an eligible client are billed to EqualityCare. If you have collected money from the client for services rendered during the eligibility period and decide to accept payment from EqualityCare, it is your responsibility to efund any client payment made for these services. r

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COMMENT

Barbara has comments on this, refer to page 48 of draft.

General Provider Information August 2003 You may, at a subsequent date, decide not to further treat the client as an EqualityCare patient. If this occurs, you must advise the client of this fact in writing before rendering treatment. You may not bill EqualityCare for services before they are provided. EqualityCare covers only those services that are medically necessary and cost-efficient. It is your responsibility to be knowledgeable regarding the covered services, limitations, and exclusions of the EqualityCare program. Therefore, if you, without mutual agreement of the client, deliver services and are subsequently denied EqualityCare payment for services that are not covered or which are covered but are not medically necessary and/or cost-efficient, you may not attempt to obtain payment from the client. If you and the client mutually agree in writing to services which are not covered (or are covered but are not medically necessary and/or cost-efficient) and you inform the client of his/her financial responsibility prior to rendering service, then you may bill the client for the services rendered.

Medical Necessity

Wyoming’s EqualityCare program is designed to assist eligible clients in obtaining medical care within the guidelines specified by Wyoming policy. EqualityCare will pay only for medical services, which are medically necessary and are sponsored under Program directives. "Medically Necessary" means the service is required to:

• Diagnose • Treat • Cure • Prevent an illness which has been diagnosed or • Is reasonably suspected to:

Relieve pain Improve and preserve health Be essential for life

The service must be:

• Consistent with the diagnosis and treatment of the patient's condition. • In accordance with standards of good medical practice. • Required to meet the medical needs of the patient and undertaken for reasons other than

the convenience of the patient or his/her physician. • Performed in the least costly setting required by the patient's condition.

Documentation, which substantiates that the client’s condition meets the coverage criteria, must be on file with the provider.

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All claims are subject to both prepayment and post payment review for medical necessity by EqualityCare. Should the review determine that services do not meet all the criteria listed above, payment will be denied, or, if the claim has been paid, action will be taken to recoup the payment for those services. EqualityCare Payment is Payment in Full

You must accept payment from EqualityCare as payment in full for a covered service. You can never bill your EqualityCare client:

• When you bill EqualityCare for a covered service, and EqualityCare denies your claim because of billing errors you made (such as wrong procedure and diagnosis codes, lack of prior authorization, invalid consent forms, unattached necessary documentation, incorrectly filled out claim form, etc.).

• When Medicare or another third party insurer has paid up to or exceeded what EqualityCare would have paid.

• For the difference in your charges and the amount EqualityCare has paid. You can bill the client:

• If you have not billed EqualityCare, the service provided is not covered by EqualityCare, and if prior to providing service you informed the client in writing that the service is non-covered and he or she is responsible for the charges.

• If the client is not EqualityCare eligible at the time you provide the services or on a plan that does not cover those particular services.

• If the client has exceeded the EqualityCare limits on physical therapy, prescriptions, and/or outpatient hospital/office visits. You can call Provider Relations or the automated voice response to determine this information.

Out-of-State Service Limitations

EqualityCare covers services rendered to EqualityCare clients when providers participating in the EqualityCare program administer the services. If services are available in Wyoming within a reasonable distance from the client's home, the client must not utilize an out-of-state provider. EqualityCare has designated the Wyoming Medical Service Area (WMSA) to be Wyoming and selected border cities in adjacent states. WMSA cities include: Idaho: Nebraska: South Dakota: Montpelier Kimball Deadwood Pocatello Scottsbluff Custer Idaho Falls Rapid City Utah: Spearfish Montana: Salt Lake City Belle Fourche Billings Ogden Bozeman Colorado: Craig

NOTE: The cities of Greeley, Fort Collins, and Denver, Colorado are excluded from the

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WMSA and are not considered border cities. EqualityCare compensates out-of-state providers within the WMSA when:

• The service is not available locally and the border city is closer for the Wyoming resident than a major city in Wyoming; and

• The out-of-state provider in the selected border city is enrolled in EqualityCare. EqualityCare compensates providers outside the WMSA only under the following conditions:

• Emergency Care - When a client is traveling and an emergency arises due to accident or illness.

• Other Care - When a client is referred by a Wyoming physician to a provider outside the WMSA for services not available within the WMSA, the referral should be documented in the provider's records. Prior authorization is not required unless the specific service is identified as requiring prior authorization.

• Children in Out-of-State Placement. If you are an out-of-state, non-enrolled provider and render services to an EqualityCare client, you may choose to enroll in the EqualityCare program and submit your claim according to Wyoming billing instructions, or bill the recipient. Out-of-state providers furnishing services within the state on a routine or extended basis must meet all of the certification requirements of the State of Wyoming. The provider must enroll in EqualityCare prior to furnishing services. Out-of –state Wyoming residents requiring Nursing Facility services must submit the following documentation upon request prior to placement in an out-of-state Nursing Facility.

• Statement by the attending physician stating the resident’s health would be endangered if he/she would be required to return to Wyoming.

• Current history and physical and comprehensive drug history. • PASRR Level I and/or Level II. • Documentation to support the “statement of endangered health,” and any other

documentation requested by the department. • The facility is a Wyoming EqualityCare provider.

Prior Authorization must be obtained from the Long Term Care Program, Aging Division. Medicare Covered Services

Claims for services rendered to clients eligible for both Medicare and EqualityCare which are furnished by an out-of-state provider must be filed with the Medicare intermediary or carrier in the state in which the provider is located, according to the standard claims filing procedures within that state. Questions concerning an individual's Medicare eligibility should be directed to the local Social Security Administration office. Usual and Customary Charges

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All charges for services submitted to EqualityCare must be made in accordance with an individual provider's usual and customary charges to the general public unless:

• A provider has entered into an agreement with the EqualityCare to provide services at a negotiated rate; or

• A provider has been directed by the EqualityCare to submit charges at an EqualityCare specified rate.

Record Keeping, Retention, and Access

Requirement

The Provider Agreement requires that the medical records fully disclose the extent of services provided to EqualityCare clients. The following elements are a clarification of EqualityCare policy regarding documentation for medical records:

• The record must be typed or legibly written. • The record must identify the patient on each page. • The record must contain a preliminary working diagnosis and the elements of a history

and physical examination upon which the diagnosis is based. • All services, as well as the treatment plan, must be entered in the record. Any drugs

prescribed, as part of a treatment, including the quantities and the dosage, must be entered in the record.

• The record must indicate the observed medical condition of the client, the progress at each visit, any change in diagnosis or treatment, and the client's response to treatment. Progress notes must be written for every office, clinic, nursing home, or hospital visit billed to EqualityCare.

Retention of Records

You must retain medical and financial records, including information regarding dates of service, diagnoses, services provided, and bills for services, for at least six years from the end of the Federal fiscal year (October through September) in which the services were rendered. If an audit is in progress, the records must be maintained until the audit is resolved. Access to Records

Under the Provider Agreement, you must allow access to all records concerning services and payment to authorized personnel of the State Auditor’s Office, the Wyoming Attorney General’s Office, the Wyoming Department of Family Services (DFS), the United States Department of Health and Human Services, and/or their designees. Records must be accessible to authorized personnel during normal business hours for the purpose of reviewing, copying and reproducing documents. DFS shall have access to your records regardless of your continued participation in the program. In addition, you are required to furnish copies of claims and any other documentation upon request from EqualityCare.

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General Provider Information August 2003 Audits and On-Site Visits

EqualityCare has the authority to conduct routine audits and on-site visits of providers in order to monitor compliance with program requirements. Audits and on-site visits may include, but are not limited to:

• Examination of records; • Interviews of providers, their associates, and employees; • Interviews of program clients; • Verification of the professional credentials of providers, their associates, and their

employees; • Examination of any equipment, stock, materials, or other items used in or for the treatment

of program clients; • Examination of prescriptions written for program clients; • Determination of whether the health care provided was medically necessary; • Random sampling of claims submitted by and payments made to providers; and/or • Audit of facility financial records for reimbursement.

You must grant the State and its representative’s access during regular business hours to examine medical and financial records related to health care billed to the program. EqualityCare notifies you before examining such records. EqualityCare reserves the right to make unscheduled visits under extraordinary circumstances, i.e., when the client's health may be endangered, when criminal/fraud activities are suspected, etc. EqualityCare is authorized to examine all your records in that:

• All eligible clients have granted EqualityCare access to all personal medical records developed while receiving EqualityCare benefits.

• All providers who have at any time participated in the EqualityCare program by signing the Provider Agreement authorizing the State to access their financial and medical records.

Your refusal to grant the State and its representative access to examine records or to provide copies of records when requested may result:

• Immediate Suspension of all Medicaid payments • All Medicaid payments made to the provider during the six year record retention period

for which records supporting such payments are not produced shall be repaid to the Office of Medicaid within ten days after written request for such repayment is made

• Suspension of all Medicaid payments furnished after the requested date of service • Reimbursement will not be reinstated until adequate records are produced or are being

maintained

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Chapter Four Utilization Review

Utilization Review ....................................................................................................................... 4-2

Complaint Referral........................................................................................................... 4-2 Release of Medical Records ............................................................................................ 4-2 Client Lock-In.................................................................................................................. 4-2

Fraud and Abuse .......................................................................................................................... 4-3 Definition of Fraud .......................................................................................................... 4-3 Definition of Abuse.......................................................................................................... 4-3 Provider Responsibility.................................................................................................... 4-3 Referral of Suspected Fraud and Abuse .......................................................................... 4-4

Sanctions .......................................................................................................................... 4-4 Adverse Action ................................................................................................................ 4-4

Report of Suspected Abuse of the EqualityCare Health Care System ............................ 4-5

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Utilization Review

The Office of Medicaid, has established a Program Integrity Unit, whose duties include, but are not limited to:

• Review of claims submitted for payment; • Review of medical records and documents related to covered services; • On-site review of medical records and client interviews; • Review of client Explanation of Medical Benefits (EOMB) responses; • Case Management oversight; • Operation of the Surveillance/Utilization Review process (SUR); and • Oversight of the Professional Review Organization (PRO) contract.

Complaint Referral

The Program Integrity Unit reviews complaints regarding appropriate use of services from providers and clients. No action is taken without a complete investigation. To file a complaint, please submit the details in writing and attach supporting documentation. Send to:

Program Integrity Unit Office of Medicaid

147 Hathaway Building 2300 Capitol Avenue Cheyenne, WY 82002

Release of Medical Records

Every effort is made to ensure the confidentiality of records in accordance with Federal Regulations and Wyoming Medicaid Rules. Medical records must be released to the agency or its designee. The signed Provider Agreement allows the Office access to medical and financial records. In addition, each client agrees to the release of medical records to the Office when they accept Title XIX benefits. The Office of Medicaid will reimburse for the copying of medical records when the agency or its agent requests records. Please attach an invoice with the records when they are submitted. Allowed reimbursements are: $5.00 retrieval fee and $0.10 per page up to 50 pages for a maximum reimbursement of $10.00 per record. Client Lock-In

EqualityCare may initiate a client lock-in program. This action can restrict clients to one physician and/or one pharmacy except for emergency services. Please check before rendering services. See pharmacy manual under “Pharmacy Lock-in” for further details.

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Fraud and Abuse

The EqualityCare program operates under the anti-fraud provisions of Section 1909 of the Social Security Act, as amended, and employs utilization management, surveillance, and utilization review. The Program Integrity Unit’s function is to perform pre- and post-payment review of services funded by EqualityCare. Surveillance is defined as the process of monitoring for service and controlling improper or illegal utilization of the program. While the surveillance function addresses itself to administrative concerns, utilization review addresses medical concerns and may be defined as monitoring and controlling the quality and appropriateness of medical services delivered to EqualityCare clients. EqualityCare may utilize the services of a Professional Review Organization to assist in these functions. Since payment of claims is made from both State and Federal funds, submission of false or fraudulent claims, statements, documents or concealment of material facts may be prosecuted as a felony in either Federal or State court. The program has processes in place for referral to the Medicaid Fraud Control Unit when suspicions of fraud and abuse arise. EqualityCare has the responsibility, under Federal Regulations and Medicaid Rules, to refer all cases of suspected fraud and abuse to the Medicaid Fraud Control Unit. In accordance with 42 CFR Part 455, 1996 Edition and Medicaid Rules, the following definitions of fraud and abuse are used:

FRAUD – “an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.” ABUSE – “provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes client practices that result in unnecessary cost to the Medicaid program.”

Provider Responsibilities

The provider is responsible for reading and adhering to applicable State and Federal regulations and the requirements set forth in this manual. The provider is also responsible for ensuring that all employees are likewise informed of these regulations and requirements. The provider certifies by his/her signature or the signature of his/her authorized agent on each claim or invoice for payment that all information provided to EqualityCare is true, accurate, and complete. Although claims may be prepared and submitted by an employee, providers are responsible for ensuring the completeness and accuracy of all claims submitted to EqualityCare.

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Referral of Suspected Fraud and Abuse

If a provider becomes aware of possible fraudulent or program abusive conduct/activity by another provider, or eligible client, the provider should notify in writing:

Quality Management/Utilization Review Unit Office of Medicaid

147 Hathaway Building 2300 Capitol Avenue

Cheyenne, Wyoming 82002 OR, contact the Medicaid Fraud Control Unit at: 1-800-378-0345 or (307) 635-3597, and send written communication to:

Medicaid Fraud Control Unit 1807 Capitol Avenue, Suite #300

Cheyenne, WY 82001-4558 Sanctions

The Office of Medicaid may invoke administrative sanctions against an EqualityCare provider who has been determined to have committed fraud, abuse, non-compliance, or who is under sanction by another regulatory entity. Providers who have had sanctions levied against them may be subject to prohibitions or additional requirements as defined by Medicaid Rules. Adverse Actions

Providers and clients have the right to request an administrative hearing regarding an adverse action taken by the Office of Medicaid program. This process is defined in Wyoming Medicaid Rule, Chapter One, and Rules for Medicaid Administrative Hearings.

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Department of Health Office of Medicaid

DAVE FREUDENTHAL, GOVERNOR

REPORT OF SUSPECTED ABUSE OF THE EQUALITYCARE HEALTH CARE SYSTEM NAME(s) OF EQUALITYCARE CLIENT/ PROVIDER: _______________________________________________

_______________________________________________

ADDRESS OF EQUALITYCARE CLIENT/ PROVIDER: _______________________________________________

_______________________________________________

_______________________________________________

TELEPHONE NUMBER OF EQUALITYCARE CLIENT/ PROVIDER:

Please give a brief description of how the EqualityCare client/provider is abusing the EqualityCare health care system. (If possible give dates of occurrence.) ________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

PLEASE CHECK ONE: EMERGENCY CARE _______ NON-EMERGENCY CARE _______

Signature of Person Reporting Abuse Date ADDRESS: ______________________________________________ Telephone #_____________ ______________________________________________ ______________________________________________

________________________________________________________________________________________ The above confidential information shall only be used to determine what action is necessary by the Department of Health, Office of Medicaid (EqualityCare).

RETURN THIS FORM TO: Quality Management/Utilization Review Manager

Office of Medicaid 147 Hathaway Building

2300 Capitol Avenue Cheyenne, WY 82002

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Chapter Five Electronic Media Claims

What is Electronic Media Claims (EMC) Submission? .............................................................. 5-2 Getting Started in EMC ............................................................................................................... 5-2 The Future in Medicaid Claims Processing..................................................................... 5-2

Benefits ............................................................................................................................ 5-2 Requirements ................................................................................................................... 5-2 Submission Methods................................................................................................................... 5-5

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What is Electronic Media Claims (EMC) Submission?

Submitting your claims via electronic media offers the advantage of speed and accuracy in claims processing. You can submit your claims through an electronic medium yourself or choose from several firms that offer electronic claim submission services. Getting Started in EMC The Future in Medicaid Claims Processing

Beginning September 29, 2003, Wyoming EqualityCare electronic health care transactions will be processed by ASC EDI Gateway, Inc., in Tallahassee, Florida. The current ACE$ software is not HIPAA compliant and cannot support an X12 837 claims transaction; therefore ACS has created the WINASAP2003 software to replace it. WINASAP2003 creates an 837 like transaction. The software is still free of charge, however, you will no longer be able to submit claims on diskette. ACS EDI Gateway has implemented a new system for claims processing. ACS EDI Gateway is offering the WINASAP2003 claims entry and submission software to replace the current ACE$ claims software. Benefits

Benefits of our WINASAP2003 system are numerous: • Free software, training, and installation; • Free claims submission 24 hours a day, 7 days a week; • Free technical support from EDI Support Unit; • Continued assistance from your Field Representative; • HIPAA ready electronic claims portal

Requirements • Windows 98 Second Edition, Windows NT, Windows 2000 or Windows XP operating

system • Pentium processor • CD-ROM drive • 50 megabytes of free disk space • 128 megabytes of RAM (256 recommended for optimal performance) • Monitor resolution of 800 x 600 pixels • Hayes compatible 9600 baud asynchronous modem • Telephone connectivity with internal or external modem installed • PC must have a printer installed in a Windows environment • Stand-alone PC – software will NOT be supported if installed on a network

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Other WINASAP2003 Information

• WINASAP2003 is not compatible with a Macintosh computer • WINASAP2003 claims cannot be transmitted via DSL or Broadband connection • All other applications must be closed when transmitting claims, i.e., transmitting

claims while using the Internet is not possible. Enrolling with ACS EDI Gateway All providers, vendors, billing agents and clearinghouses who are submitting claims electronically will need to complete the Wyoming ACS EDI Provider or Submitter Enrollment form. They will also need to complete either the Trading Partner Agreement, or Trading Partner and Business Associate Agreement. These forms are available on the EDI website at http://www.acs-gcro.com. Once the enrollment forms are completed, sent to EDI and entered by EDI, providers and submitters will receive a six-digit Trading Partner ID number. You must have this number available when contacting EDI. WINASAP2003 users will also receive a user login ID and password for WINASAP2003. These numbers will not take the place of your current nine-digit Wyoming EqualityCare provider ID number. When submitting a claim, be sure to use your nine-digit Wyoming EqualityCare provider number on the claim. Helpful Billing Tips for WINASAP2003 Before billing through WINASAP2003, there are required fields that must be completed under the File and Reference portions of the WINASAP2003. File:

Trading Partner Information - This area is where you will enter your Trading Partner ID number, contact information and WINASAP2003’s host phone number when it becomes available. You will also need to enter the user ID and password assigned to you by EDI. This information will only need to be entered one time; WINASAP2003 will then save it for you.

Reference:

Provider List – This is where you will add your provider information, such as your nine-digit Wyoming EqualityCare provider number, address, contact information and tax-ID number. WINASAP2003 will save this information for you; you will not have to enter it again unless you receive a new or additional provider number, etc.

Patient List – This is where you will add the client information, such as their EqualityCare ID number, patient account number, date of birth, address and their EqualityCare insurance information. WINASAP2003 will save this information for you; you will not have to enter it again unless there is a change in the client’s information. NOTE: The Trading Partner, Provider and Patient information must be entered into

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http://www.acs-gcro.com/


these screens before you will be able to transmit a claim. Other Reference File Information The reference screen in WINASAP2003 will also allow you to save procedure codes, diagnosis codes and revenue codes. This is not mandatory. However, if you have a code that has multiple charges, you will only be allowed to save one charge per code. You will not want to save these particular codes in your reference file, but rather type them individually when entering a claim. Providers must individually key all procedure, diagnosis and revenue codes into the reference file. They cannot be downloaded from another file. WINASAP2003 will not support this function. Claims Transactions WINASAP2003 does not have the capability of supporting the 835 claims transaction. However, it will be able to receive a 997 transaction, which is the functional acknowledgement transaction (was your file accepted or rejected) and the 824 transaction, which is the error report (did your claim meet the minimum requirements or business edits to be processed by the MMIS). Providers will also be able to submit adjustments electronically through WINASAP2003. Please refer to the “Claim Frequency Type Code” field on each claim type in WINASAP2003. This field is where you will indicate if the transmission is an original claim, a replacement claim, or if you want the claim to be voided. Claims Submission Methods

Providers may use one or more methods for submitting claims and receiving data. The methods listed below will help you determine your data submission options.

• Dial-up Using WINASAP2003 WINASAP2003 is available free to providers from ACS EDI Gateway. No Internet access is needed. WINASAP2003 replaces ACE$.

• Dial-up Using other Software Providers may also use other software not supplied by ACS EDI Gateway to submit batches of claims via ordinary phone lines.

• Clearinghouse A clearinghouse is a company that accepts claims from a provider and routes them to fiscal agents and other payers.

• Billing Agent A billing agent is a company that acts as a third party to providers, actually billing or entering the electronic claims on behalf of the providers.

If you wish to submit your EqualityCare claims using to ACS EDI Gateway electronically, please contact:

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ACS EDI Gateway Services

Technical Support for WINASAP 2003 providers: 1-800-672-4959 (8am to 5pm MST)

or Technical Support for Vendors, Billing Agents, Clearing House:

1-850-201-1171 (8am to 5pm MST)

Note: All providers who currently submit claims electronically MUST enroll with EDI. Failure to enroll timely with EDI will delay processing of provider enrollment and claims payment. Providers who bill with WINASAP2003 will NOT need to submit a test file to EDI. The WINASAP2003 software has already been tested. All billing agents and clearinghouses must test with EDI before submitting a test file.

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Chapter Six Verifying Client Eligibility

What is EqualityCare............................................................................................................... 6-2 Who is Eligible?..................................................................................................................... 6-3 Eligibility Determination ....................................................................................................... 6-4

Responsible Agency .................................................................................................. 6-4 Services Available ................................................................................................................. 6-4 Limitations ............................................................................................................................. 6-7 Definition of Plans ................................................................................................................. 6-8 Client Identification Cards................................................................................................... 6-10 Other Types of Eligibility Identification ............................................................................. 6-10

Presumptive Eligibility ............................................................................................ 6-10 Clients Without Cards.......................................................................................................... 6-10

Responsibility for Provider Payment ....................................................................... 6-10 Medicare Eligibility ............................................................................................................. 6-11

Description of Medicare Benefits ............................................................................ 6-11 Services Provided in Wyoming ............................................................................... 6-11

Client Lock-In...................................................................................................................... 6-11 Freedom of Choice............................................................................................................... 6-12 Verification of Client Eligibility.......................................................................................... 6-12

Client Identification ................................................................................................. 6-12 Verification of Client Age ....................................................................................... 6-12

Verification Options ............................................................................................................ 6-13 Automated Voice Response (AVR)..................................................................................... 6-14 Provider Terminal Network ................................................................................................. 6-14 Assistance to Potential Eligibles.......................................................................................... 6-15 Presumptive Eligibility ........................................................................................................ 6-16

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What is EqualityCare?

EqualityCare is the name chosen by the Wyoming Department of Health for its public health insurance programs. These programs are designed to help pay for medically necessary health care services for low-income children and families, aged, blind and disabled persons. The programs use state and federal money to pay for these services. The programs that fall under the heading of EqualityCare are:

• AIDS Drug Assistance Program (ADAP) • EqualityCare

Aged/Blind/Disabled Family Care Hospice Care Presumptive eligibility for Pregnant Women Qualified Medicare Beneficiary (QMB) Special Low Income Medicare Beneficiary (SLIMB)

• EqualityCare For Children • Foster Care • Children’s Special Health (CSH)

High Risk Maternal Newborn Intensive Care

• EqualityCare Home and Community Based Service (HCBS) Waivers Long Term Care (LTC) Waiver Adult Developmental Disabilities (DD) Waiver Children’s Developmental Disabilities (DD) Waiver Acquired Brain Injury (ABI) Waiver Assisted Living Facility (ALF) Waiver

• Prescription Drug Assistance Program (PDAP) • Marginal Dental Program (MDP) • Nursing Home Services • State Licensed Shelter Care • Wyoming Breast and Cervical (BCC) • EDI- Employed Disabled Individuals Program

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Who is Eligible?

Anyone belonging to one or more of the groups listed below is eligible for EqualityCare Health Insurance Programs.

• Parent(s) with child (ren) whose income is at or below the 1996 guidelines set forth in the Aid to Families with Dependant Children (AFDC) Act may be eligible for the Family Care Plan.

• Pregnant women whose income is less than 133% of the Federal Poverty Level. • Pregnant women receiving specialized perinatal care for a high risk pregnancy at a Level III

facility whose household income is less than 185% of the Federal Poverty Level may be eligible for the High Risk Maternal (HRM) program within Children's Special Health (CSH).

• Infants born to a woman who is receiving EqualityCare services under the Pregnant Women's program at the time of birth. The parent(s) of newborn child(ren) should notify their local Department of Family Services (DFS) office of the child(ren)'s birth.

• Infants receiving newborn intensive care at a Level III facility and meeting medical eligibility requirements whose household income is less than 185% of the Federal Poverty Level may be eligible for the Newborn Intensive Care (NBIC) program within Children's Special Health (CSH).

• Children from infancy to age six (6) whose parent(s) income is less than 133% of the Federal Poverty Level may be eligible for EqualityCare for Children.

• Children age six (6) through age eighteen (18) whose parent(s) income is less than 100% of the Federal Poverty Level may be eligible for EqualityCare for Children.

• Certain Foster Care children under 21 years of age. • Certain children, newborn through age eighteen (18), with special health care needs and

household income of less than 185% of the Federal Poverty Level may be eligible for the Children's Special Health (CSH) program.

• Those eligible for Supplemental Security Income (SSI), which includes persons who are aged, blind or disabled. If you think that you may be eligible for SSI benefits, contact your Social Security Administration office.

• Those who have lost SSI eligibility due to Cost Of Living Adjustment (COLA) increases, earned income increases, and/or child support increases may qualify for another program.

• Qualified Medicare Beneficiaries (QMB) - services are limited to the payment of their Medicare premiums, coinsurance and deductibles.

• Specified Low-Income Medicare Beneficiaries (SLIMB) - benefits are limited to the payment of their Medicare Part B premiums only.

• Individuals who require nursing home care and reside in an EqualityCare certified nursing facility meeting State requirements.

• Those receiving Home and Community-Based Waiver (HCBS) services including, but not limited to: Assisted Living Facility, Developmentally Disabled Adults and Children, the Elderly and Physically Disabled, and Acquired Brain Injury.

• Those eligible under the Prescription Drug Assistance Program (PDAP) can receive help with the cost of pharmacy and oxygen services.

• Qualified and non-qualified aliens are eligible for emergency services only. • Employed Disabled Individual (EDI) Program- Individuals who are disabled as defined by

the Social Security Administration and their working income is at or less than 100% of the Federal Poverty level.

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• Wyoming Breast and Cervical Cancer (WBCC)- This program covers preventative and diagnostic services related to breast and cervical cancer. Women’s Health Source will determine who qualifies for this program.

• AIDS Drug Assistance Program (ADAP)- This is a pharmacy services only program. There are no age restrictions. The AIDS Program will determine who qualifies for ADAP.

• Marginal Dental Program- a co-payment program for children up to their 19th birthday. Families must complete the Dental Health Services applications for this program and the child (ren) cannot be on EqualityCare for Children.

Eligibility Determination Responsible Agency

Eligibility determination for the EqualityCare program is the responsibility of the Department of Family Services (DFS) through its local field offices. Determination of eligibility for SSI is the responsibility of the Federal Social Security Administration through the SSA District Offices. Appendix A lists the locations and telephone numbers of the SSA District Offices. Appendix B lists the mailing address, physical location, and telephone numbers of all DFS local offices. What services are available through the EqualityCare programs?

General descriptions of services available through various programs are listed below. All services are not covered by all of the programs. Read carefully because there are limitations and restrictions. These benefits may change without notice.

• Acquired Brain Injury (HCBS) Waiver Services: Home and community based services to qualified eligible adults ranging from age 21 to age 64 with an acquired brain injury and specified functioning levels.

• Adult DD (HCBS) Waiver Services: Home and community based services to qualified eligible adults with mental retardation or developmental disabilities age 21 and older.

• Ambulance Services: Emergency transportation by Basic Life Support, Advanced Life Support or air ambulance. Some non-emergency ambulance transportation may also be covered if the patient needs special care during the trip and if any other means of travel would put the patient in danger.

• Ambulatory Surgical Center Services: Outpatient surgery performed in a freestanding facility. See Surgical Services for more information.

• Assisted Living Facility (HCBS) Waiver Program: Provides funding for clients who are eligible for nursing home. Funding is provided for personal care, 24-hour supervision, and medication assistance in an assisted living facility. Clients are responsible for their own room and board.

• Child DD (HCBS) Waiver Services: Home and community based waiver services to qualified children and young adults under age 21 with mental retardation or developmental disabilities.

• Community Mental Health Center (CMHC) Services: Mental health and substance abuse services when provided by a CMHC.

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• Dental Services: Standard EqualityCare: Comprehensive services for children and young adults under

the age of 21. Adults are covered only for emergency visits for pain and/or infection. Crippling Malocclusion: Applications are currently being accepted for clients

between the ages of 10 and 21 with severe bite problems (crippling malocclusion). A separate application is available from your local Public Health Nurse for the treatment of this condition. The application must be completed even if the child is on EqualityCare for Children.

The Marginal Dental Program is a co-payment program for children up to their 19th birthday. Families must complete the Dental Health Services application for this program and the child (ren) cannot be on EqualityCare for Children. The state pays for 85%, up to a maximum of $1000 every three years. The client is responsible for 15% and any amounts over the $1000 cap.

• Developmental Center Services: Developmental assessments and therapy services for children age 5 and younger.

• Developmental Disabilities (HCBS) Waiver Programs: Specific home or community-based services for clients with developmental disabilities who would otherwise require entrance to an Intermediate Care Facility for the Mentally Retarded (ICF-MR). See above.

• End-Stage Renal Disease (ESRD) Services: Medicare is the primary sponsor for ESRD services. EqualityCare sponsors medically necessary services related to renal disease care according to specified guidelines provided the client is enrolled in both programs. The client is a patient of an enrolled, certified ESRD facility or a kidney transplant recipient needing assistance with immunosuppressant medicine.

• Family Planning Services: A physician or nurse practitioner or a Family Planning Clinic furnishes Family planning services to individuals of childbearing age. Pregnancy testing as well as contraceptive supplies and devices are covered. This includes Norplant and Depo-Provera. Infertility services are not covered.

• Federally Qualified Health Center (FQHC) Services: There is an encounter rate per visit for services provided in clinics designated as an FQHC.

• Health Check Exams: Comprehensive well-child screening, diagnostic and treatment services for children and young adults under 21 years of age. Services must be provided by a physician, nurse practitioner, midwife or Public Health Nurse and may include lab tests.

• Hearing Services: Services of an audiologist and hearing aids. • Home Health Services: Skilled medical services provided by a home health agency to

patients under a physician's plan of care. • Hospice Services: Services delivered in a patient's home under a doctor's order to terminally

ill patients of any age. The services are only for care related to the terminal illness during the last months of the person's life.

• Hospital Services: Inpatient and outpatient services with some exceptions. Alcohol and chemical rehabilitation services are not covered for client’s age 21 and older. Psychiatric care is limited to acute care stabilization and must be prior authorized. Independent psychiatric care for clients under 21 years of age is available with prior authorization. There are limits on emergency-room visits for non-emergency reasons for client’s age 21 and older. A co-payment is required for any non-emergency visits for client’s age 21 and older. See Surgical Services for limitations on surgical procedures.

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• Intermediate Care Facility for the Mentally Retarded (ICF-MR) Services: Long- term care in a facility for mentally retarded clients who are unable to live outside the institution.

• Laboratory and X-ray Services: Including X-ray, ultra-sound, radiation therapy and nuclear medicine services, if ordered by a physician or nurse practitioner. Also annual routine pap-tests and screening mammography.

• Long Term Care (HCBS) Waiver Program Services: Services in the community offered to clients who would otherwise need to enter a nursing home. Clients may stay in their home and receive specialized care. Clients opting for these services may use any other covered services, except nursing home care or another waiver.

• Medical Supplies and Equipment: Medically necessary equipment and supplies, if ordered by a physician. These services may be obtained through a pharmacy or medical supplier and may require prior authorization by EqualityCare.

• Mental Hospital Services: Inpatient hospital services for clients of all ages in need of immediate inpatient psychiatric care is covered in acute care general hospitals. For clients under the age of 21, extended inpatient psychiatric care may be available in enrolled psychiatric hospitals. Residential Treatment Center services are available for clients under 21.

• Nurse Practitioner and Nurse Midwife Services: Services provided by nurse-midwives, adult, pediatric, OB/GYN and geriatric nurse practitioners, when permitted by state law.

• Nursing Facility Services: Services for individuals with medical needs who are unable to continue to live in the community. These services are subject to pre-admission screening for medical necessity.

• Organ Transplant (including Bone Marrow) Services: Medically necessary transplants are limited to clients under the age of 21 and require prior authorization.

• Physician Services: Most services provided by physicians or other medical practitioners under the supervision of a physician. Certain surgical procedures require prior authorization or consent forms. A co-payment may be required for patients age 21 and over.

• Physical Therapy Services: Restorative physical therapy provided under written orders of a physician. Services must be provided through a hospital, physician's office or by an independent physical therapist.

• Prescription Drugs: Most prescription and some over-the-counter drugs are covered. A prescription is required for all drugs. A co-payment may be required for client’s age 21 and older. For the Prescription Drug Assistance Program there is a limit of three (3) prescriptions per month including over-the-counter drugs. Exceptions to co-payment may apply for specific products or conditions.

• Prosthetics and Orthotics: Most services are covered; prior authorization is required in some cases.

• Radiology Services: See Laboratory and X-ray Services. • Rehabilitation Services: Services to restore movement, speech or other functions after an

illness or injury, when provided in outpatient rehabilitation facilities. • Residential Treatment Center Services: Services are available for clients under 21. • Rural Health Clinic (RHC) Services: There is an encounter rate per visit for services

provided by a clinic designated as a Rural Health Clinic. • Surgical Services: Only medically necessary surgical procedures. Covered surgeries may be

performed in a hospital as an inpatient or outpatient, in an ambulatory surgical center, or in a physician's office.

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• Transportation Services: Payment for travel for medical services received out of town is available through your local DFS office. Ask your caseworker how to obtain these services.

• Vision Services: Comprehensive services including eyeglasses for clients under the age of 21, with limits, when provided by an ophthalmologist, optometrist or optician. Clients age 21 and older are eligible for eye examinations for treatment of disease or injury only.

• Waiver Services: Home and Community-Based services as indicated within this section. Limits and Restrictions to the EqualityCare programs

EqualityCare will NOT pay for the following services: • Abortion, except as specified by Federal Law. • Acupuncture. • Alcohol and chemical rehabilitation are not covered. Treatment is limited to stabilization

of acute conditions. • Autopsies. • Biofeedback therapies and equipment. • Cancelled or missed appointments. • Chiropractic services, except where Medicare is the primary insurance. • Chronic pain rehabilitation • Community mental health services furnished outside of Wyoming. • Cosmetic procedures and surgeries performed when a non-surgical alternative is

available or those performed only for the convenience of the patient. • Custodial care in a hospital. • Educational supplies and equipment. • Examinations or reports required for legal or other purposes not specifically related to

medical care. • Experimental procedures. • Infertility services including reverse sterilization, counseling and artificial insemination. • Organ Transplants (including Bone Marrow) are limited to clients under the age of 21. • Personal comfort items. • Physician visits are limited to 12 per calendar year for clients age 21 and older. • Physical Therapy visits are limited to 20 per calendar year for client’s age 21 and older. • Podiatrist services, except where Medicare is the primary insurance- • Private duty nursing services. • Services provided to someone who is outside the United States. • Services provided to someone who is in emergency detention. • Services provided to someone who is an inmate of a public institution or is in the custody

of state, local, or federal law enforcement agency. • Services that are not medically necessary. • Services that are not prescribed by a physician. • Services that are performed by a provider who is not enrolled with EqualityCare. • Transsexual surgery. • Waiver services do not pay for room and board. • Waiver services will not be furnished while the client is an inpatient of a hospital, nursing

facility or other institution.

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Definition of Plans

• Aliens Eligible for Emergency Services - Aliens are eligible for emergency services defined as, after sudden onset, a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate attention could reasonably be expected to result in:

Placing the patient's health in serious jeopardy; or Serious impairment to bodily functions (includes labor and deliver only); or Serious dysfunction of any bodily organ or part.

Emergency service will not pay for services related to either an organ transplant procedure or routine prenatal or post-partum care.

• Children’s Special Health (CSH) provides services for children with special health care needs. CSH covers a broad array of congenital defects, chronic diseases, disabling conditions and conditions that allow for rehabilitation. Services are available for Wyoming infants and children under 19 years of age and high-risk pregnant women and newborns who require Level III hospital care. Children can be dual eligible with other EqualityCare programs.

• Home and Community-Based Waiver programs are managed by the Department of Aging and the Developmental Disabilities Division. For each DD waiver program an individualized written plan of care will describe the medical, supportive and other services to be furnished, their frequency, and the type of provider who will furnish each service. Programs available through DD are:

Acquired Brain Injury Program, which offers limited services to a target group of individuals ranging in age from twenty-one (21) through sixty-four (64) with acquired brain injury and specified functioning levels.

Adult Program provides home and community-based services to qualified mentally challenged or developmentally disabled adults age 21 and over.

Child Program provides home and community-based services to qualified children from birth through twenty (20) years of age.

The Department of Aging has the responsibility for the remaining two waiver programs that provide care in the home for nursing home eligible people. Each person has a plan of care developed by his or her case manager and approved by the Department of Aging. Those programs are: Long Term Care Waiver Program provides home and community-based

services to qualified EqualityCare eligible persons, 19 years and older, who but for the provision of such services, would require the level of care provided in a nursing facility.

Assisted Living Facility Waiver provides services to EqualityCare clients, 19 years and older and who qualify for nursing home care, the ability to have their care provided in an assisted living facility. The client is responsible for paying their room and board fee and EqualityCare funds the care required within the facility at a daily rate.

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• Dental Health Services manages the Medicaid dental program as well as: Marginal Dental Program – This is a dental program for low-income children

under the age of 21. Dental Health pays 85% and the client pays 15%. Elderly Dental Program – This is a dental program for low-income individuals

age 65 and older. Dental Health pays 85% and client pays 15%. It helps pay for dentures for seniors.

Sealants Dental Program – This is a dental program that pays for sealants. Crippling Malocclusion – Clients under the age of 21 may receive treatment for

severe crippling malocclusion. • Maternal Dental Care Services – Pregnant women over 21 qualify for routine services.

Best Beginnings determine eligibility. • Medicare Qualifying Individuals - These individuals are entitled to Medicare Part B,

Have income of 101-135% FPL, resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for EqualityCare. EqualityCare pays only for their Part B premiums (Premiums change each calendar year).

• Prescription Drug Assistance Program - A state only program, which provides limited drug coverage and oxygen benefits for low-income individuals. The client is limited to three (3) prescriptions per month. Name brand drugs have a $25.00 co-payment. Generic drugs have a $10.00 co-payment. Oxygen services are also covered, but not supplies.

• Newborns - A newborn infant is automatically eligible for EqualityCare if his/her mother is eligible at the time of birth. Care rendered to the newborn must be billed under the newborn’s Client Identification Number. Parents are responsible for notifying the local DFS field office to enroll the newborn so that a Client Identification Number can be assigned. Refer to Chapter Seven for billing instructions.

• Presumptive Eligibility - This program enables a woman who is pregnant and meets the program's financial guidelines to qualify and receive quicker access to ambulatory prenatal care. Qualified providers who are in Public Health Nursing offices, Indian Health Services, and certain private physician’s offices determine presumptive eligibility. Once a woman is found to be eligible under the Presumptive Eligibility program, she will receive an eligibility period card. The services that are covered for these women are physician visits, lab tests and x-rays, emergency room visits, prescriptions, medical supplies and community health services. No inpatient hospital services are covered under the Presumptive Eligibility program for pregnant women. Pregnant women can receive dental services through the Maternal Dental Care Services program (see above).

• Qualified Medicare Beneficiaries - These individuals are entitled to Medicare Part B, have income of 100% Federal poverty level (FPL) or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for EqualityCare. EqualityCare pays for their Medicare Part B premiums, Medicare deductibles and coinsurance for Medicare services provided by EqualityCare providers.

• Qualified Working Disabled Individuals – These individuals have lost their Medicare Part A benefits due to their return to work. They are eligible to purchase Medicare Part A benefits, have income of 200% FPL or less and resources that do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for EqualityCare. EqualityCare pays the Medicare Part a premium only.

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• Special Low-Income Medicare Beneficiaries - These individuals are entitled to Medicare Part A and B, have income of 100 – 135% FPL and resources do not exceed twice the limit for SSI eligibility, and are not otherwise eligible for the programs. EqualityCare pays their Medicare Part B premiums only.

Client Identification Cards

The EqualityCare swipe cards are mailed to clients upon enrollment into the Wyoming public health insurance programs. Eligibility information is electronically updated within the system. This information may be confirmed through MEVSNET, a Medifax machine, or by contacting ACS via the Provider Relations toll free number, AVR or fax. A complete listing of ways to check eligibility is provided later in this chapter. An example of the EqualityCare card is below:

Other Types of Eligibility Identification

Presumptive Eligibility - White Card

A pregnant client who is determined to be a presumptive eligible is given a presumptive eligibility period card. This card is only for information for the provider until the pregnant woman receives the EqualityCare Card (See Exhibit 6.1 for sample ID card.) Recipients on PE are eligible for outpatient services and prescriptions only. Clients Without Cards

Responsibility for Provider Payment

Any client who seeks service without a valid EqualityCare Identification Card is responsible for all charges.

If a client cannot produce a Client Identification Card upon your request you may: • Require the client to return with the card • Inquire regarding client eligibility by contacting ACS, Inc.'s Provider Relations Unit, the

Automated Voice Response system if you have the client's ID or Social Security Number available to you, or by using Medifax or Mevsnet.com.

NOTE: Telephone verification of client eligibility is not binding for reimbursement.

If you do not accept the client as an EqualityCare patient (because they cannot provide a card or because they do not inform you that they are eligible) and you agree at a later date to accept EqualityCare benefits:

• You must refund the entire amount paid by the client prior to billing EqualityCare; and • Timely filing requirements will not be waived.

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In cases of retroactive eligibility when a provider agrees to bill EqualityCare for services provided during the retroactive eligibility period:

• You must refund the entire amount paid by the client prior to billing EqualityCare; and • Timely filing requirements will be waived.

EqualityCare will not pay for services rendered to clients until eligibility has been determined for the month services were rendered. Medicare Eligibility

Description of Medicare Benefits

Medicare is a hospital and medical insurance program administered by the Social Security Administration for covered persons who are either 65 years of age or older, blind, totally and permanently disabled, or have end-stage renal disease. The Railroad Retirement Board administers a similar Medicare program for former Railroad workers and their dependents.

• Part A (Hospital Insurance) of Medicare pays the expenses of a patient in a hospital, skilled nursing facility, or at home when receiving services provided by a home health agency.

• Part B (Medical Insurance) helps pay for physician services, outpatient hospital services, inpatient ancillary charges when Part A benefits are exhausted or nonexistent, medical services and supplies, home health services, outpatient physical therapy, and other health care services. Medicare limits payment to certain covered services deemed medically necessary in order to maximize the medical benefits that can be obtained with limited funds.

Services Provided in Wyoming

For clients who are also eligible for Medicare benefits, EqualityCare buys into Medicare Part B and Part A, where applicable, by paying the insurance premium. By paying the Medicare insurance premiums, EqualityCare furnishes payment toward services covered by Medicare and EqualityCare up to the agency's established Title XIX limit. In addition to the Part B coverage furnished to these individuals, some clients may have Part a coverage either by having worked a sufficient number of quarters to be eligible to receive Part A coverage or by purchasing Part A coverage. EqualityCare clients may have Medicare coverage. The provider should ask to see the Medicare card to determine the extent of the client's Medicare coverage. Client Lock-In

In certain circumstances, it may be necessary to restrict certain services or "lock-in" a client to a certain physician or other provider. If a lock-in restriction applies to a client, the lock-in information is given on the AVR, as described in this chapter.

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A participating EqualityCare provider who is not designated as the client's primary practitioner may provide and be reimbursed for services rendered to lock-in clients only under the following circumstances:

• In a medical emergency situation where a delay in treatment may cause death or result in lasting injury or harm to the client.

• As a physician covering for the designated primary physician or on referral from the primary physician.

In cases where lock-in restrictions are indicated, it is the responsibility of each provider to determine whether he/she may bill for services provided to a lock-in client. Contact ACS, Inc. at (800) 251-1268 in circumstances where coverage of lock-in clients is unclear. See pharmacy manual for details regarding Pharmacy Lock-in. Freedom of Choice

Any eligible non-restricted client may select any provider of health services in Wyoming who participates in the EqualityCare program, unless EqualityCare specifically restricts his/her choice through Provider Lock-in or an approved Freedom of Choice waiver. However, payments can be made only to health service providers who are enrolled in the EqualityCare program. Verification of Client Eligibility

Eligibility verification is your responsibility as an EqualityCare provider; possession of an EqualityCare ID card is not a guarantee of eligibility. EqualityCare will only pay for covered services performed during the period of eligibility. It is, therefore, in the provider's interest to check each time a service is rendered. Client Identification

It is your responsibility to verify that the person receiving services is the same person listed on the card. If necessary, you should request additional materials to confirm identification. It is illegal for anyone other than the person named on the Client Identification Card to obtain or attempt to obtain services by using the card. Providers who suspect misuse of a card should report the occurrence to the Office of Medicaid at (307) 777-7531. Verification of Client Age

Because certain services have age limitations, such as services covered only under the Health Check program and requirements of informed consent for sterilizations, you should verify the client's age before a service is rendered.

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Verification Options

In July 2001, Wyoming Public Health Insurance Programs replaced the monthly coupons issued to clients with plastic ID swipe cards. One EqualityCare swipe card is issued to each client. Their eligibility information is updated electronically every month. The presentation of a card is no longer verification of eligibility; it is your responsibility as a provider to ensure that your patient is eligible for the services rendered. A client may state that he or she is covered by EqualityCare, but not have any proof of eligibility. This can occur if the client is newly eligible or if his or her card was lost. Eligibility Verification Systems (EVS) offer you current eligibility information about EqualityCare clients enabling you to know their coverage limits before you render services. You have several options when checking patient eligibility:

• Call Provider Relations at ACS, Inc. at 1-800-251-1268, or (307) 772-8401 locally, available from 9:00 am – 5:00 pm Monday – Friday, except State holidays, at no charge (There is a limit of three verifications per call but no limit on the number of calls).

• Fax a list of identifying information to ACS, Inc. for verification at (307) 772-8405; send a list of beneficiaries for verification and receive a response on the same day (short list, early receipt), next day (longer list, late-day receipt), or within 72 hours for more extensive requests, at no charge.

• Call the Automated Voice Response System at 1-800-251-1270 or (307) 772-8403, available 24 hours a day, seven days a week, at no charge (there is a limit of three verifications per call but no limit on the number of calls).

• Purchase a Medifax machine for use with the swipe card; or • Sign up with MEVSNET.

Full use of the swipe card requires contracting with a vendor to provide eligibility information. The two vendors that have been authorized to provide eligibility verification in Wyoming are MediFax, Inc. and Mevsnet.com. MediFax

MediFax (1-800-444-4336) has been providing service in Wyoming since 1993. They provide a full-service swipe card reader for point-of-service transactions. There is a cost for the swipe card reader, plus a monthly cost, in addition to a transaction fee. This option requires an analog telephone line and two electrical outlets. No dedicated phone line is required, but depending on office telephone volume, you may want to put it on a non-primary line or a computer modem line. The subscription offers access to more than 140 additional payer databases including Medicaid, Medicare and private insurance plans, plus data verification from Trans-Union’s ScorePlus and TRACE credit/coverage verification services. The MediFax card reader can replace your existing credit card reader so you need only one device. (Most credit card readers do not have enough memory to support the MediFax service.) MediFax also provides an Internet product with the same pricing and options as the swipe card reader product. This Internet product does not support claims inquiry or remittance advices at this time. Other products are available for high-end integration with provider networks.

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Mevsnet

Mevsnet.com (1-800-333-4979) provides an Internet-based verification for EqualityCare, EqualityCare for Children and other Wyoming Department of Health programs. There is a monthly cost plus a transaction fee. Installation includes a swipe card reader that attaches to an existing computer and requires a modem and Internet connection through a dial-up Internet Service Provider. This option offers on-line electronic Remittance Advice, recent payment history, status of submitted claims. (Note: ACS owns Mevsnet but is an independent vendor, not part of the Wyoming ACS, Inc. contract.) All services provide extensive information about the beneficiary’s eligibility and benefits. Information includes service limitations and caps, lock-in status if applicable, nursing home indicator, Medicare information, and information on two insurance carriers for easy compliance with third-party billing requirements. Automated Voice Response (AVR)

ACS, Inc.’s Automated Voice Response System provides a service to the EqualityCare provider community by allowing direct access to the following information:

• Client eligibility status; • Service limitations; • Third party liability insurance company and policy number; • Payment data; • EqualityCare number and information;

If you have a touch-tone telephone, ACS, Inc.'s Voice Response System provides a synthesized voice response to eligibility related inquires. You can access the system using the Client Identification Number and date of birth or Social Security Number and date of birth. Complete instructions are provided over the telephone. The AVR telephone number is 1-800-251-1270 or (307) 772-8403. If you have a rotary dial telephone, please call the Provider Relations Unit, Monday through Friday, 9 a.m. to 5 p.m. at (307) 772-8401 or 1-800-251-1268 outside Cheyenne. Provider Terminal Network

Eligibility information is also available to you by establishing direct access to ACS, Inc.'s data center. Private vendors provide this service. Through their telecommunications networks, you are connected with the ACS, Inc. system. This service is possible using a personal computer, point-of-sale device, or computer terminal installed in your office. For further information regarding EVS, contact ACS, Inc.'s Provider Relations Unit Monday through Friday, 9 a.m. to 5 p.m. at (307) 772-8401 or 1-800-251-1268 outside Cheyenne.

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Assistance to Potential Eligibles

If you think a client may qualify for an EqualityCare program, you need to direct the client to apply at their local Department of Family Services (DFS) office. EqualityCare assumes no financial responsibility for services rendered prior to the effective date of client eligibility as determined by DFS or the SSA. If the client is deemed eligible, however, the effective date of eligibility as determined by DFS may be retroactive up to three months prior to the month in which the application is filed, as long as the client was eligible during each month of the retroactive period. If SSA deems the client eligible, the period of original entitlement could precede the application date beyond the customary 90-day retroactive eligibility period and/or the 12-month filing deadline. This situation could arise for the following reasons:

• Administrative Law Judge decisions or reversals; • Delays encountered in processing applications or receiving necessary client information

concerning income or resources. In some cases, a provider may be presented with a copy of a Notice of Award in lieu of the Client's EqualityCare Card. If you furnish services to a client who presents a Notice of Award, you should contact ACS, Inc. to verify eligibility. The EqualityCare program covers certain medical services for pregnant women, children and infants who may not otherwise qualify for EqualityCare services. Those eligible are pregnant women and children up to age six whose income is less than 133 percent of the Federal Poverty Level. Providers caring for pregnant women who may qualify for these benefits should direct potential clients to their local DFS field office.

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Presumptive Eligibility

WYOMING DEPARTMENT OF HEALTH OFFICE OF MEDICAID

WOMAN'S PRESUMPTIVE ELIGIBILITY PERIOD CARD ELIGIBLE FROM DATE: / / ENDING DATE / / SOCIAL SECURITY NUMBER - - NAME: QUALIFIED PROVIDER: ADDRESS: PROVIDER ADDRESS: STATE: ZIP INSURANCE NAME (IF ANY) PROVIDER PHONE # INSURANCE NUMBER THIS IS A NOTIFICATION THAT THE WOMAN INDICATED ABOVE HAS BEEN FOUND TO BE ELIGIBLE FOR PRESUMPTIVE ELIGIBILITY. THE WOMAN WILL RECEIVE AN EQUALITYCARE CARD WITHIN 2 WEEKS FROM THE ELIGIBLE FROM DATE INDICATED ABOVE. IF THE EQUALITYCARE CARD IS NOT RECEIVED WITHIN THAT TIME THE WOMAN NEEDS TO CALL 1-800-251-1269. THE EQUALITYCARE CARD WILL CONTAIN THE CLIENT IDENTIFICATION NUMBER WHICH IS USED FOR MEDICAL PROVIDER BILLING. WOMAN'S SIGNATURE / / DATE QUALIFIED PROVIDER SIGNATURE

BILLING INFORMATION TO THE CLIENT:

1. You will receive an EqualityCare card within approximately 2 weeks from the eligible from date. You will need to present the EqualityCare card to all your medical providers.

TO THE PROVIDER:

1. Providers who want a client ID number before the individual receives their EqualityCare card can call ACS, Provider Relations Unit at 1-800-251-1268 and receive the client ID number for billing. ACS will have a client ID number if the presumptive application was received from the qualified provider.

2. Providers can call the AVR system at 1-800-251-1270 to get a client ID number. 3. The Client ID 0699999999 billing number will no longer be accepted when billing for presumptive

eligibility. See number 1 and 2 above on how to obtain the client ID number. 4. ONLY outpatient ambulatory prenatal services will be reimbursed. 5. The program adopts the Wyoming EqualityCare reimbursement policies and payment rates.

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Chapter Seven Common Billing Information

Where to Send Your Claim......................................................................................................7-2 Authorized Signatures..............................................................................................................7-2 Cap Limit Waivers...................................................................................................................7-2 How to Bill for Newborns........................................................................................................7-3 No Show Appointments...........................................................................................................7-3 Medicare Crossovers................................................................................................................7-3 General Information.....................................................................................................7-3 How to File a Claim for a Dually Eligible Client ........................................................7-3 Prior Authorization ..................................................................................................................7-4 How to Complete the Prior Authorization Form .......................................................7-7 Required Attachments and How to Complete .........................................................................7-9 Attachment Cover Sheet ............................................................................................7-10 Consent Forms .......................................................................................................................7-11

Sterilization Consent Form ........................................................................................7-13 Hysterectomy Acknowledgment of Consent .............................................................7-15 Abortion Certification................................................................................................7-17

The Remittance Advice (RA) ................................................................................................7-18 When Your Patient Has Other Insurance...................................................................7-19

Sample Remittance Advices ......................................................................................7-20 How to Read Your Remittance Advice .....................................................................7-24 How to Resubmit a Denied Claim .........................................................................................7-26 Adjustments and Refunds ......................................................................................................7-26 Refunding Money to EqualityCare ............................................................................7-26 Incorrectly Billed or Keyed Claims ...........................................................................7-27 Third Party Recovery After EqualityCare’s Payment ...............................................7-27 How to File a Void or Adjustment Request...............................................................7-27 How to Complete the Adjustment Request Form......................................................7-29 Timely Filing .........................................................................................................................7-30

Timely Filing Criteria ................................................................................................7-30 Exceptions to the Twelve Month Limit .....................................................................7-30 Appeal of Timely Filing.............................................................................................7-30 Important Information Regarding Retroactive Eligibility Decisions ........................7-31 Failure of Eligible Client to Notify Provider of EqualityCare Eligibility .................7-31 Billing Tips to Avoid Timely Filing Denials.............................................................7-31 Filing Deadlines for Adjustments ..............................................................................7-32

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This chapter addresses billing requirements and forms common to all claim types. Specific billing instructions for each claim type can be found in the Billing Modules. Where to Send Your Claim

Send your claim forms to: ACS, Inc./Claims P.O. Box 547 Cheyenne, WY 82003-0547

When ACS receives your claim, it is screened for missing information or necessary attachments. If either the provider number and/or the authorized provider signature are missing, the claim is returned with a "Return to Provider Letter" (RTP). The claim does not enter the claims processing system. You need to correct the error or attach the missing document to the claim and return it to the ACS, Inc. post office box for processing. ACS, Inc. and the Office of Medicaid are prohibited by federal law from altering a claim. There are reasons a claim is returned to you. The RTP will clearly state the reason the claim was rejected. Once the problem is corrected, return the claim to ACS, Inc. for processing. Claims are processed daily. Checks are printed weekly. Under normal conditions, a claim can be processed from receipt to payment within five to ten days. A check is mailed in the same envelope with the Remittance Advice.

Authorized Signatures

All paper claims must be signed. You or your authorized representative may sign. Acceptable signatures may be either handwritten, a stamped facsimile, typed, computer generated, or initials. The signature certifies that all information on the claim is true, accurate, complete, and contains no false or erroneous information.

Cap Limits

EqualityCare clients over 21 years of age are limited to 12 office and/or outpatient hospital visits. They are also limited to 20 physical therapy visits and 2 emergency dental visits.

Cap Limit Waivers

Physicians and physical therapists may request a waiver of the cap limitation for clients once the cap limit has been reached. Submit a letter citing the specific medical necessity for a waiver of the cap limit to ACS, Inc. at PO Box 667, Cheyenne, WY 82003. A physician or nurse practitioner must sign waiver requests for physician visits. Requests for waiver of the cap on physical therapy visits must be signed by a physical therapist or nurse practitioners. For further information please contact the Provider Relations unit at ACS, Inc.

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How to Bill for Newborns

A newborn number will need to be obtained by the mother from the Department of Family Services. The newborn will receive an EqualityCare card of their own, with their own recipient ID number. The name on the card will be “unborn.” Bill these newborn claims as any other EqualityCare claim.

No Show Appointments

Canceled or missed appointments by EqualityCare clients cannot be billed to EqualityCare. However, if your office policy is to bill all patients for canceled or missed appointments, then you can bill EqualityCare clients for these no show appointments. EqualityCare only pays physicians for services they provide, i.e. services as identified in 1905 (a) of the Social Security Act. They must accept that payment as full reimbursement for their services in accordance with 42 CFR 447.15. Missed appointments are not a distinct, reimbursable EqualityCare service. Rather, they are considered part of a provider’s overall cost of doing business. The EqualityCare reimbursement rates set by the State are designed to cover the cost of doing business and providers may not impose separate charges on the recipients. Medicare Crossovers

EqualityCare reimburses for Medicare/EqualityCare services when provided to an eligible client. General Information

• Dually eligible clients are clients who are eligible for Medicare and EqualityCare. • Providers must accept assignment of claims for dually eligible clients. • The State of Wyoming reimburses providers for 100 percent of deductible and

coinsurance amounts due on Medicare covered services for dually eligible clients. How to File a Claim for a Dually Eligible Client

• Medicare is primary and must be billed first. Direct your questions related to Medicare claims processing to the Medicare carrier.

• Claims must: Be a legible photocopy of the claim submitted to Medicare or completed

according to Medicare billing instructions. Have your nine-digit EqualityCare number. Have attached a copy of the Medicare EOMB.

The time limit for filing Medicare crossover claims to EqualityCare is twelve months from the date of service or six months from the Medicare payment date, whichever is later.

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Prior Authorization

EqualityCare requires prior authorization (PA) on certain services and equipment. Approval of PA is not a guarantee of coverage or client eligibility. Services must not be provided without confirming the client’s eligibility and obtaining a PA if required. The provider is responsible for obtaining a prior authorization. Providers will have three ways to request and receive prior authorization: through the paper process, through the X12 278 transaction, and the web based option. Paper Process In order to request Prior Authorization, providers can continue to call the authorizing agency (CFMC or ACS), submit PA information by fax, mail or receive pending authorization by phone. To order PA forms, refer to Chapter Two of this manual or make copies from the example provided here. The instructions for completion of the PA request follow this section. Once the PA request has been reviewed, it will either be approved, denied, or pended and a PA letter will be sent communicating the information. X12 278 Transaction Providers will have a new option, to submit PA requests electronically to ACS using the X12 278 format. Providers will be able to receive the authorization itself from ACS on paper or electronically in X12 278 format, depending on which way the PA has been requested. For example, if the provider requests a PA electronically, they will receive the authorization electronically. Approval

If the paper PA is approved, a PA approval letter is mailed. If the electronic PA is approved, an X12 278 will be sent. A PA number is listed on the approval letter. This number must be in field 23 of the CMS-1500 claim form. The provider must receive the approval before services are rendered. EqualityCare will not reimburse for services if the provider fails to obtain a PA for those services that require PA. Denial

If the PA request is denied, the provider may request reconsideration. This request must be in accordance with EqualityCare Rules. Emergency

A pending PA may be granted by telephone in cases of medical emergency, if the health of the client is endangered. To obtain emergency PA, call (307) 772-8401 locally or 1-800-251-1268 outside of Cheyenne. A prior authorization request with the pending PA number must be submitted within 30 days of receiving the PA number and must include all documentation required.

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Services requiring prior authorization include: • Vision Therapy • Surgical Procedures which include but are not limited to gastric bypass and breast reduction • Vagus Nerve Stimulation • Cochlear Implants • DD Waiver Services (the Plan of Care is approved by the Division of Developmental

Disabilities). • LTC Waiver Services (the Plan of Care is approved by the Aging Division). • Inpatient Psychiatric and Rehabilitation Services (CFMC) • Residential Treatment Centers (CFMC) • Extraordinary Care (CFMC)

If you have any questions regarding PAs, please contact ACS, Inc. You may also refer to the CFMC Provider Manual for further information.

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7-6

EXHIBIT 7.1 Sample Prior Authorization Form

EQUALITYCARE PRIOR AUTHORIZATION FORM

I. PATIENT INFORMATION

II. PROVIDER INFORMATION 1. DOB

2. SEX

3. AGE

4. EqualityCare ID#

9. PROVIDER NUMBER

10. TELEPHONE

5. PATIENT NAME (LAST, FIRST, MI)

11. PROVIDER NAME

6. STREET ADDRESS

STREET ADDRESS

7. CITY, STATE, ZIP CODE

MAILING ADDRESS

8. PHONE NUMBER ( ) -

CITY, STATE, ZIP CODE

III. SERVICE INFORMATION 12. DATES OF SERVICE MM/DD/YY FROM TO

13. PROPOSED MEDICAL SUPPLIES, PHARMACY, SURGICAL PROCEDURES OR OTHER SERVICES, (LIST PRIMARY PROCEDURE FIRST)

14. PROCEDURE, NDC OR REVENUE CODE(S)

15. UNITS

16. ESTIMATED COST

17. STATE USE ONLY-APPROVED UNITS AMOUNTS

A. B. C. D.

18. SUMMARY OF HISTORY (DIAGNOSIS, DATE OF ONSET, PROGNOSIS, PHYSICAL EXAMINATION, LABORATORY, X-RAY STUDIES, PHARMACY, AND APPLICABLE DOCUMENTATION MUST BE SUPPLIED IN SUFFICIENT DETAIL TO SATISFY THE MEDICAL NECESSITY FOR THE PRESCRIBED SERVICE. ADDITIONAL DOCUMENTATION MAY BE ATTACHED WHEN NECESSARY.)

19. REFFERRING WYOMING PHYSICIAN: TELEPHONE NUMBER: (IF THIS AUTHORIZATION REQUEST IS FOR SERVICE TO BE RENDERED OUT-OF-STATE, A BRIEF JUSTIFICATION STATEMENT IS REQUIRED)

20. VERBAL AUTHORIZATION GIVEN BY: DATE: PA NUMBER: 21. TO THE BEST OF MY KNOWLEDGE, THE ABOVE INFORMATION IS TRUE, ACCURATE, AND COMPLETE AND THE REQUESTED SERVICES ARE MEDICALLY INDICATED AND NECESSARY TO THE HEALTH OF THE PATIENT. SIGNATURE OF PROVIDER: DATE:

IV. AUTHORIZATION (FOR STATE USE ONLY) AUTHORIZATION IS VALID FOR SERVICES 22. FROM DATE: 23. TO DATE: 24. PRIOR AUTHORIZATION NUMBER 25. COMMENTS/EXPLANATION:

NOTE:AUTHORIZATION DOES NOT GUARANTEE PAYMENT. PAYMENT IS SUBJECT TO THE PATIENT'S ELIGIBILITY AND WYOMING BENEFIT LIMITATIONS. BE SURE THE EQUALITYCARE IDENTIFICATION CARD IS CURRENT BEFORE RENDERING SERVICES.

ACS, INC. * P.O BOX 667 * CHEYENNE, WY 82003 1-800-251-1268 * (307) 772-8401 (In Cheyenne) * FAX: (307) 772-8405

HCF/UMU1056/93 6/93


Instructions for Completion of the Prior Authorization Form Item Number

Title

Action

1

Date of Birth

Enter MMDDYY of client's date of birth.

2

Sex

Enter client's sex.

3

Age

Enter client's age.

4

EqualityCare Identification Number

Enter the client's ten-digit EqualityCare ID number.

5

Patient's Name

Enter last name, first name, and middle initial exactly as it appears on the EqualityCare ID Card.

6

Patient's Address

Enter the street address, including P.O. Box and apartment number, where client resides.

7

City, State, Zip Code

Enter the city, state, and zip code at which the client resides.

8

Phone Number

Enter the telephone number of the client.

9

Provider Number

Enter nine-digit unique EqualityCare provider number.

10

Provider Telephone Number

Enter area code and telephone number of provider, including extension, if appropriate.

11

Provider Name and Address

Enter provider name as it appears on the provider enrollment form, with street address or P.O. Box, city, state, and full zip code.

12

Date(s) of Service

Enter the date(s) of service this prior authorization will cover.

13

Proposed Services

Enter narrative description of service(s) being prior authorized.

14

Procedure/NDC/ Revenue Codes

Codes for the service(s) being prior authorized should reflect narrative description.

15

Units

Enter number of each service being prior authorized.

16

Estimated Cost

Enter dollar amount times the units for each service being prior authorized.

17

State Use Only

To be completed by the State evaluator.

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Item Number

Title

Action

18

Summary of History

Please give as much information as possible supporting the need for the service(s) requested. You may attach additional sheets if necessary.

19

Out-of-State Justification

Under "Wyoming Referring Physician," enter the name or the provider number of the Wyoming physician referring the client for out-of-state services. Under "Phone Number," enter the phone number of the referring Wyoming physician. The justification of out-of-state services can be brief and can relate to number 19.

20

Verbal Authorization

Enter the name verbal authorization was given by, the date authorization was given, and the PA number.

21

Signature/Date

The form should be signed by the entity requesting prior authorization of services, with the date of the signature.

22-25

State Use Only

Wyoming EqualityCare will complete these items when prior authorization is approved.

Send Prior Authorization Form to:

ACS, Inc. P.O. Box 667

Cheyenne, WY 82003

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Required Attachments and How to Complete

When providing EqualityCare services, certain procedures or conditions require that other forms be used in addition to the claim form when billing for reimbursement. This section describes each required form and tells you how to prepare it for submission. Refer to the Covered Services and Limitations modules for specific attachment requirements. Examples of attachments include:

• Operative Report • Ambulance Trip Report • Documentation of Medical Necessity • Invoice • Sterilization Consent Form (Exhibit 7.2) • Hysterectomy Consent Form (Exhibit 7.3) • Abortion Consent Form (Exhibit 7.4) • Hospice Pharmacy Waiver • Swing Bed Exemption Letter • Medicare EOMB • TPL EOB

ACS now has a process for joining paper attachments with electronically submitted claims. Therefore, if you want to submit your claim electronically and then mail your required attachment, you can. You can also continue to mail the paper claim and attachment together. If you electronically submit your claim and then mail you attachment, you must indicate on your electronic claim that a paper attachment is being mailed and then send you paper attachment with the Attachment Cover Sheet completed. If you do not follow both of the above steps, ACS will not know how to join these and your claim will be denied. If your attachment is not received within 30 days of your claim submission, your claim will be denied as well and you will have to resubmit it with the proper attachments.

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Attachment Cover Sheet

Wyoming EqualityCare Program

Attachment Cover Sheet Please use this form when submitting a claim electronically which requires an attachment. The attachment canbe submitted on paper along with this cover sheet. If this cover sheet is not attached to your documentationyour request CANNOT be processed. You MUST submit one cover sheet for each type of document.Documents sent without a cover sheet will be shredded.

Provider Name __________________________________________________________ Pay-to-Provider Number Client Name ______________________________________________________________ Client EqualityCare ID Number Date of Service (MMDDYY)

Type of Document – One must be checked A – Ambulance Trip Report C – Consent Form (Abortion, Hysterectomy, Sterilization) H – Hospice Pharmacy Waiver I – Invoice M – Medicare EOMB O – Operative Reports P – Prior Authorization Form and/or Documentation S – Swing bed Exemption Letter T – Third Party Liability Documentation (EOB’s, Denial Letters, Letters attempting to collect)

RETURN THIS DOCUMENT WITH ATTACHMENTS TO: ACS State Healthcare

P.O. Box 547 Cheyenne, WY 82003

Attachment Control Number – For Office Use Only

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Consent Forms Sterilization Consent Form

Federal regulations require that clients give written consent prior to sterilization for EqualityCare to reimburse you for these procedures. The Sterilization Consent Form is obtained from ACS, Inc. The Sterilization Consent Form must be attached to all claims for EqualityCare reimbursement of sterilization related procedures as mandated by the Federal Government. All sterilization claims must be processed according to the following Federal guidelines:

FEDERAL GUIDELINES

The waiting period between consent and sterilization must not exceed 180 days and must be at least 30 days, except in cases of premature delivery and emergency abdominal surgery. The day the client signs the consent form and the surgical dates are not included in the 30-day requirement. A client signs the consent form on July 1. To determine when the waiting period is completed, count 30 days beginning on July 2. The last day of the waiting period would be July 31; therefore, surgery may be performed on August 1.

In the event of premature delivery, the consent form must be completed and signed by the client at least 72 hours prior to the sterilization, and at least 30 days prior to the expected date of delivery.

In the event of emergency abdominal surgery, the client must complete and sign the consent form at least 72 hours prior to sterilization. The consent form supplied by the surgeon must be attached to every claim for sterilization-related procedures; i.e., ambulatory surgical center clinic, physician, anesthesiologist, inpatient or outpatient hospital. Any claim for a sterilization-related procedure which does not have a signed and dated, valid consent form will be denied. All blanks on the consent form must be completed with the requested information. The consent form must be signed and dated by the client, the interpreter (if one is necessary), the person who obtained the consent, and the physician who will perform the sterilization. The physician statement on the consent form must be signed and dated by the physician who will perform the sterilization on the date of the sterilization or after the sterilization procedure was performed. The date on the sterilization claim form must be identical to the date and type of operation given in the physician's statement.

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Use the following instructions to complete the Sterilization Consent Form. PART 1 CONSENT TO STERILIZATION 1 Enter the name of the physician or the name of the clinic from which the client received

sterilization information. 2 Enter the type of operation (no abbreviations). 3 Enter the client's date of birth (MM/DD/YY). 4 Enter the client's name. 5 Enter the name of the physician performing the surgery. 6 Enter the name of the type of operation (no abbreviations). 7 The client to be sterilized signs name here. 8 The same client in #7 dates signature here. 9 Check one box appropriate for client. This item is requested but NOT required. PART 2 INTERPRETER'S STATEMENT 10 Enter the name of the language the information was translated to. 11 Interpreter signs name here. 12 Interpreter dates signature here. PART 3 STATEMENT OF PERSON OBTAINING CONSENT

13 Enter client's name. 14 Enter the name of the operation (no abbreviations). 15 The person obtaining consent from the client signs here. 16 The person obtaining consent from the client dates signature here. 17 The person obtaining consent from the client enters the name of the facility where the person

obtaining consent is employed. The facility name must be completely spelled out. 18 The person obtaining consent from the client enters the complete address of facility in #17 above.

Address must be complete, including state and zip code. PART 4 PHYSICIAN'S STATEMENT 19 Enter the client's name. 20 Enter the date of sterilization operation. 21 Enter type of operation (no abbreviations). 22 Check applicable box:

• If premature delivery is checked, you must write in the expected date of delivery here.

• If emergency abdominal surgery is checked, describe circumstances here. 23 Physician who performs the sterilization signs here. 24 The physician's signature must be dated.

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EXHIBIT 7.2 Sterilization Consent Form

HCF-01

Sterilization Consent Form

NOTICE: YOUR DECISION AT ANY TIME NOT TO BE STERILIZED WILL NOT RESULT IN THE WITHDRAWAL OR WITHHOLDING OF ANY BENEFITS PROVIDED BY PROGRAMS OR PROJECTS RECEIVING FEDERAL FUNDS. CONSENT TO STERILIZATION

1 I have asked for and received information about sterilization from _________________. When I first asked for the information, I was told that the decision to be sterilized is completely up to me. I was told that I could decide not to be sterilized. If I decide not to be sterilized, my decision will not affect my right to future care or treatment. I will not lose any help or benefits from programs receiving Federal funds, such as A.F.D.C. or EqualityCare that I am now getting or for which I may become eligible.

I UNDERSTAND THAT THE STERILIZATION MUST BE CONSIDERED PERMANENT AND NOT REVERSIBLE. I HAVE DECIDED THAT I DO NOT WANT TO BECOME PREGNANT, BEAR CHILDREN OR FATHER CHILDREN.

I was told about those temporary methods of birth control that are available and could be provided to me which will allow me to bear or father a child in the future. I have rejected these alternatives and chosen to be sterilized.

I understand that I will be sterilized by an operation known as a 2 ___________________. The discomforts, risks and benefits associated with the operation have been explained to me. All my questions have been answered to my satisfaction.

I understand that the operation will not be done until at least thirty days after I sign this form. I understand that I can change my mind at any time and that my decision at any time not to be sterilized will not result in the withholding of any benefits or medical services provided by federally funded programs.

I am at least 21 years or age and was born on 3 ______________________. Month Day Year

4 I, ________________________________, hereby consent of my own free will to be sterilized by 5 ____________________________(doctor) by a method called 6 _______________________________. My consent expires 180 days from the date of my signature below.

I also consent to the release of this form and other medical records about the operation to: Representatives of the Department of Health and Human Services or Employees of programs or projects funded by that Department but only for determining if Federal laws were observed.

I have received a copy of this form. 7 _________________________________ Date:___________________________ 8

Signature Month Day Year 9 You are requested to supply the following information, but it is not required: Race and ethnicity designation (please check) __American Indian or Alaska Native __Black (not of Hispanic origin) __Asian or Pacific Islander __Hispanic __White (not of Hispanic origin)

INTERPRETER'S STATEMENT

If an interpreter is provided to assist the individual to be sterilized:

I have translated the information and advice presented orally to the individual to be sterilized by the person obtaining this consent. I have also read him/her the consent form in 10 ______________________ language and explained its contents to him/her. To the best of my knowledge and belief he/she understood this explanation.

11 ____________________________ 12 ____________________________ Signature of Interpreter Date

STATEMENT OF PERSON OBTAINING CONSENT

Before 13 ___________________________________ (name of individual) signed the consent form, I explained to him/her the nature of the sterilization operation 14 ______________, the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent.

I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or any benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appears to understand the nature and consequence of the procedure.

15 ________________________________________ 16 ___________________________ Signature of person obtaining consent Date

17 ________________________________________________________________________ Facility

18 ________________________________________________________________________ Address

PHYSICIAN'S STATEMENT

Shortly before I performed a sterilization operation upon 19 ____________________________ (name of individual to be sterilized) on 20 _______________________________, (date of sterilization operation)

I explained to him/her the nature of the sterilization operation 21 ________________, (specify type of operation) the fact that it is intended to be a final and irreversible procedure and the discomforts, risks and benefits associated with it.

I counseled the individual to be sterilized that alternative methods of birth control are available which are temporary. I explained that sterilization is different because it is permanent.

I informed the individual to be sterilized that his/her consent can be withdrawn at any time and that he/she will not lose any health services or benefits provided by Federal funds.

To the best of my knowledge and belief the individual to be sterilized is at least 21 years old and appears mentally competent. He/She knowingly and voluntarily requested to be sterilized and appeared to understand the nature and consequences of the procedure.

Instructions for use of alternative final paragraphs: Use the first paragraph below except in the case of premature delivery or emergency abdominal surgery where the sterilization is performed less than 30 days after the date of the individual's signature on the consent form. In those cases, the second paragraph below must be used. Cross out the paragraph which is not used.

(1) At least thirty days have passed between the date of the individual's signature on this consent form and the date the sterilization was performed.

(2) This sterilization was performed less than 30 days but more than 72 hours after the date of the individual's signature on this consent form because of the following circumstances (check applicable box and fill in information requested):

� Premature delivery 22 � Individual's expected date of delivery: ______________(Date)

� Emergency abdominal surgery: (describe circumstances):

23 _________________________________ 24 __________________ Physician Date

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Hysterectomy Acknowledgment of Consent

A copy of the completed Hysterectomy Acknowledgment of Consent form must be attached to each claim form when billing for hysterectomy related services before EqualityCare will consider the claim for payment. The originating physician is required to supply other billing providers (e.g., hospital, surgeon, anesthesiologist, etc.) with a copy of the completed Hysterectomy Acknowledgment of Consent form. Use the following instructions to complete the Hysterectomy Consent Form. PART A CONSENT OBTAINED PRIOR TO SURGERY 1 Enter the name of the physician performing the surgery. 2 Enter the narrative diagnosis for the client's condition. 3 The client receiving the surgery signs here and dates. 4 The person explaining the surgery signs here and dates.

PART B CONSENT OBTAINED AFTER SURGERY 5 Enter the date and the physician’s name that performed the hysterectomy. 6 Enter the narrative diagnosis for the client's condition. 7 The client receiving the surgery signs here and dates. 8 The person explaining the surgery signs here and dates.

PART C NO CONSENT IS OBTAINED 9 Enter the narrative diagnosis for the client's condition. 10 Check applicable box:

• If other reason for sterility is checked, you must write what was done. • If previous tubal is checked, you must enter the date of the tubal. • If emergency situation is checked, you must enter the description.

11 The physician who performed the hysterectomy signs here and dates.

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EXHIBIT 7.3 HYSTERECTOMY CONSENT FORM

HYSTERECTOMY ACKNOWLEDGMENT OF CONSENT

Complete PART A if consent is obtained PRIOR to surgery It is anticipated that 1 _______________________________ will perform a hysterectomy on me. I understand that there are medical indications for this surgery. It has been explained to me and I understand that this hysterectomy will render me permanently incapable of bearing children. 2 Diagnosis:_____________________________________________________________________________________ 3 Signature of Patient:____________________________________ Date:___________________________________ 4 Signature of Person Explaining Hysterectomy:__________________________________ Date:___________________________________ ====================================================================================== Complete PART B if consent is obtained AFTER surgery 5 On_______________________________________ _________________________________________________ (Date) (Physician) performed a hysterectomy on me. I understand that there were medical indications for this surgery. Prior to the procedure the doctor again explained to me that this surgery would render me permanently incapable of bearing children. 6 Diagnosis:_____________________________________________________________________________________ 7 Signature of Patient:_________________________________________ Date:_____________________________ 8 Signature of Person Explaining Hysterectomy:_______________________________________ Date:____________________________ ==================================================================================== COMPLETE PART C IF NO CONSENT IS OBTAINED 9 Diagnosis:_____________________________________________________________________________________ 10 Check which is applicable: [ ] Other reason for sterility:

__________________________________________________________________________________________ __________________________________________________________________________________________

[ ] Previous tubal Date:_________________________________________ [ ] Emergency situation (describe) __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________ _____________________________ 11 Physician Signature Date _____________________________________________________________________________________________________ HCF-03

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General Provider Information

Abortion Certification

The EqualityCare Abortion Certification form must accompany all claims for abortion related services. This requirement includes, but is not limited to, claims from the attending physician, assistant surgeon, anesthesiologist, pathologist, and hospital. Refer to a sample of the form and instructions for completing the form on subsequent pages in this chapter. Use the following instructions to complete the Abortion Certification Form. 1 Enter the name of the attending physician or surgeon. 2 Check the option (1, 2, or 3) that is appropriate for the client. 3 You must enter the name of the client receiving the surgery and their address. 4 The attending physician or surgeon signs here. 5 Enter the performing physician's address.

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EXHIBIT 7.4 Abortion Certification Form

ABORTION CERTIFICATION FORM

I, Doctor 1 ____________________________________________, certify that:

2 ___ (1) My patient suffers from a physical disorder, physical injury, or physical

illness including a life-endangering physical condition caused by or arising from the pregnancy itself, that would place her in danger unless an abortion is performed; or

___ (2) This pregnancy is a result of sexual assault as defined in W.S. 6-2-301 which

was reported to a law enforcement agency within five days after the assault or within five days after the time the victim was capable of reporting the assault; or

___ (3) The pregnancy is the result of incest. Patient Name: _____________________________________ Address: _____________________________________ 3

_____________________________________

Physician Signature: _________________________________ 4

Address: _________________________________ 5 _________________________________

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General Provider Information

The Remittance Advice

The Remittance Advice (RA) plays an important communication role between you and EqualityCare. It tells you what happened to the claims submitted for payment - whether they were paid, pended, or denied. Aside from providing a record of transactions, the RA assists you in resolving possible errors so that you can resubmit denied claims. An electronic 835 Remittance Advice is available by contacting ACS EDI at 1-800-672-4959 or 1-850-201-1171. Electronic RA’s will show the standard claim adjustment reason and payment remark codes (the same as Medicare and other payers). Paper RA’s will continue to show EqualityCare’s current explanation of benefits (EOB) codes.

• Claims are grouped by disposition category. For example, paid, denied, and pended claims and claim adjustments are listed in separate sections.

Claim Status PAID group contains all the paid claims. If you have been paid for a claim that you later decide should not have been billed to EqualityCare, refer to “How to File a Void or Adjustment Request” in this chapter for instructions. You can only void or adjust a paid claim.

Claim Status DENIED group reports denied claims. If you have new or additional information that might make a denied claim payable, you may rebill it (see “How to Resubmit a Denied Claim” in this chapter).

Claim Status PENDED group reports claims pended for review. Do not rebill these claims. You cannot adjust or void pended claims. All claims in pended status are reported each payment cycle until paid or denied.

• All paid, denied, and pended claims and claim adjustments are itemized within each group in alphabetic order by client last name.

• Transaction Control Numbers (TCNs) are assigned to all of the claims in the batch as they are microfilmed. The TCN assigned to each claim allows the claim to be tracked throughout the EqualityCare system. The digits and groups of digits in the TCN have special meanings, as explained in this example:

0 03180 22 001 0001 00 | | | | | | | | | | | | | Line Number (00 except for pharmacy claims) | | | | | | | | | | | Claim Number | | | | Type of Document (0=new claim, 1=credit, 2=adjustment) | | | Batch Number | | | | | Imager Number | Year/Julian Date Claim Input Medium Indicator …………………… 0=Exam entered 1=Point of Sale

2=Tape-to-tape 3=WINASAP2003 4=Computer generated (Adjustment)

5=Special Batch

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The RA Summary Section reports the number of claim transactions, and total payment, or check amount. If your account with ACS, Inc. shows a prior negative balance, it will be carried forward from week to week until eliminated. EqualityCare cannot send out an RA with a negative balance. It is extremely important for provider’s to work and review their RA’s every week (that one is received); if a previous negative balance is paid off for example, three weeks after the original adjustment is done, the current RA will not tell you who the original adjustment was done on, therefore it is imperative that the remittance advices are worked upon receipt. Obtain Your RA from the Web You are now able to view and download your last 8 RA’s from the EqualityCare Website. Go to http://wyequalitycare.acs-inc.com. Click on “New Users” and then complete the online enrollment form, you will then receive an acceptance letter via email. When Your Patient Has Other Insurance

If the client has other insurance coverage reflected in EqualityCare records, payment will be denied unless you report the coverage on your claim. EqualityCare is always the payer of last resort except for prenatal, absent parent policies, and Health Check claims. To help you file with the other carrier, the following information is provided on the RA directly below the denied claim:

• Insurance carrier name, • Name of insured, • Policy number, • Insurance carrier address, • Group number, if applicable and • Group employer name and address, if applicable.

Record other insurance coverage information reported on the RA on your client's file for future use. The information below the denied claim regarding third party liability is specific to the individual client. The Third Party Resources Information Sheet (see Exhibit 8.2) is for reporting new insurance coverage or changes in insurance coverage on a client's policy. Complete the form and send to ACS, Inc. for processing.

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http://wyequalitycare.acs-inc.com/


Exhibit 7.5 Sample Remittance Advices

See the subsequent pages for a description of the RA item numbers. Professional RA Sample: REMITTANCE ADVICE WYMC8000-R001 (CP-O-12) WYOMING DEPARTMENT OF HEALTH AS OF 07/02/03 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/07/03 R E M I T T A N C E A D V I C E TO: SAMPLE OF A COUNTY PUBLIC HEALTH OFFICE R.A. NO.: 0480283 DATE PAID: 07/02/03 PROVIDER NUMBER: 111111111 PAGE: 1 TRANS-CONTROL-NUMBER BILLED MCARE COPAY OTHER DEDUCT- COINS MCAID WRITE TREATING LI SVC-DATE PROC/MODS UNITS AMT. PAID AMT. INS. IBLE AMT. PAID OFF PROVIDER S PLAN * * * CLAIM TYPE: LTC SCREENING * * * CLAIM STATUS: DENIED ORIGINAL CLAIMS: * BUSH GEORGE RECIP ID: 0000012345 PATIENT ACCT #: 0-03175-22-250-0006-10 80.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 HEADER EOB(S): 300 147 01 04/28/03 W7101 1 80.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 111111111 K LTCS * GORE ALBERT RECIP ID: 0600123456 PATIENT ACCT #: 0-03175-22-250-0006-12 80.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 HEADER EOB(S): 300 147 01 05/02/03 W7101 1 80.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 111111111 K NH REMITTANCE ADVICE TO: A SAMPLE COUNTY PUBLIC HEALTH OFFICE R.A. NO.: 0480283 DATE PAID: 07/02/03 PROVIDER NUMBER: 111111111 PAGE: 2 REMITTANCE T O T A L S PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 4 --------- 320.00 0.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 --------- 0.00 0.00 AMOUNT OF CHECK: ------------------------------------------------------------ 0.00 ---- THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT: 147 THE TREATING PROVIDER TYPE IS NOT VALID WITH THE PROCEDURE CODE. 4 300 THE PROVIDER NUMBER CANNOT BE BILLED ON THIS CLAIM TYPE. VERIFY YOU ARE 4 USING THE CORRECT PROVIDER NUMBER FOR THIS CLAIM TYPE AND RESUBMIT.

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General Provider Information August 2003 Institutional RA Sample: REMITTANCE ADVICE WYMC8000-R001 (CP-O-12) WYOMING DEPARTMENT OF HEALTH AS OF 07/02/03 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/07/03

R E M I T T A N C E A D V I C E

TO: A SAMPLE HOME HEALTH R.A. NO.: 0479556 DATE PAID: 07/02/03 PROVIDER NUMBER: 122222222 PAGE: 1 COVERED PERIOD COVER BILLED OTHER PAID BY WRITE TRANS-CONTROL-NUMBER FROM TO DAYS LOC AMT. INS. MCAID OFF PLAN * * * CLAIM TYPE: INPATIENT * * * CLAIM STATUS: PAID ORIGINAL CLAIMS: * KENNEDY HAROLD RECIP ID: 0600234567 PATIENT ACCT #: 215580100 5-03164-22-376-0001-00 05/01/03 05/31/03 31 14 5693.77 0.00 5693.77 0.00 KIDA REMITTANCE T O T A L S PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 1 ------- 5,693.77 5,693.77 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 ------- 0.00 0.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 0 ------- 0.00 0.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 ------- 0.00 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 ------- 0.00 0.00 AMOUNT OF CHECK: ------------------------------------------------------------ 5,693.77 ---- THE FOLLOWING IS A DESCRIPTION OF THE LEVEL OF CARE CODES THAT APPEAR ABOVE: COUNT:

14 SPECIAL INPATIENT RTC 1

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Dental RA Sample: REMITTANCE ADVICE WYMC8000-R001 (CP-O-12) WYOMING DEPARTMENT OF HEALTH AS OF 07/02/03 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/07/03

R E M I T T A N C E A D V I C E

TO: A SAMPLE DENTAL OFFICE R.A. NO.: 0479427 DATE PAID: 07/02/03 PROVIDER NUMBER: 133333333 PAGE: 1 TRANS-CONTROL-NUMBER BILLED OTHER PAID BY COPAY WRITE TREATING DATE TTH CD/SURF PROC/MODS UNITS AMT. INS. MCAID AMT. OFF PROVIDER S PLAN FEE * * * CLAIM TYPE: DENTAL * * * CLAIM STATUS: PAID

ORIGINAL CLAIMS:

* ROSS DERRICK RECIP ID: 0600345678 PATIENT ACCT #: 0000000000000 0-03176-22-151-0023-00 86.00 0.00 72.00 0.00 14.00 LI: 001 06/23/03 00120 1 33.00 0.00 25.00 0.00 8.00 133333333 F KIDA M01 LI: 002 06/23/03 01110 1 53.00 0.00 47.00 0.00 6.00 133333333 F KIDA M01 REMITTANCE T O T A L S PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 2 --------- 151.00 129.00 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 --------- 0.00 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 --------- 0.00 0.00 AMOUNT OF CHECK: ------------------------------------------------------------ 129.00

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General Provider Information August 2003 Pharmacy RA Sample: REMITTANCE ADVICE WYMC8000-R001 (CP-O-12) WYOMING DEPARTMENT OF HEALTH AS OF 07/01/03 MEDICAID MANAGEMENT INFORMATION SYSTEM RUN DATE 08/07/03 R E M I T T A N C E A D V I C E TO: A SAMPLE PHARMACY R.A. NO.: 0481131 DATE PAID: 07/01/03 PROVIDER NUMBER: 144444444 PAGE: 1 **** PATIENT NAME **** RECIPIENT FIRST LAST ADJUST BILLED OTHER PAID BY WRITE LAST FIRST MI IDENT NUM TRANS-CONTROL-NUMBER SVC DATE SVC DATE RSN. AMT. INS. MCAID OFF PLAN * * * CLAIM TYPE: GROSS ADJUSTMENT * * * CLAIM STATUS: PAID ADJUSTMENT CLAIMS: 0000000000 4-03189-00-998-1001-20 07/08/03 07/08/03 86 0.45- 0.00 0.45- 110.00 TO: A SAMPLE PHARMACY R.A. NO.: 0481131 DATE PAID: 07/01/03 PROVIDER NUMBER: 144444444 PAGE: 2 DISPENSE RX NO. BILLED PAID BY MCARE DEDUCT- OTHER PAID BY COPAY WRITE PLAN TRANS-CONTROL-NUMBER DATE AMT. MCARE COINS. IBLE INS. MCAID AMT. OFF * * * CLAIM TYPE: PHARMACY * * * CLAIM STATUS: PAID ORIGINAL CLAIMS: * EMONDS STEVEN RECIP ID: 0600089517 1-03178-10-700-0381-31 06/27/03 8117140 1782.55 0.00 0.00 0.00 0.00 1782.55 0.00 0.00 WLTC PRACTITIONER: JOHN SMITH, M.D. LINE NATIONAL DRUG CODE/ D R U G N A M E BILLED SUB PAID PAID BY WRITE S NO. PRODUCT SERVICE ID AMT. UNITS UNITS MCAID OFF 001 44087002203 REBIF 0.00 12.00 12.00 1782.55 0.00 B LINE EOB(S): 788 REMITTANCE ADVICE TO: A SAMPLE PHARMACY R.A. NO.: 0481131 DATE PAID: 07/01/03 PROVIDER NUMBER: 144444444 PAGE: 3 REMITTANCE T O T A L S PAID ORIGINAL CLAIMS: NUMBER OF CLAIMS 2 ---- 3,565.10 3,028.35 PAID ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 2 ---- 1,783.00- 1,783.00- DENIED ORIGINAL CLAIMS: NUMBER OF CLAIMS 1 ---- 1,782.55 0.00 DENIED ADJUSTMENT CLAIMS: NUMBER OF CLAIMS 0 ---- 0.00 0.00 PENDED CLAIMS (IN PROCESS): NUMBER OF CLAIMS 0 ---- 0.00 0.00 AMOUNT OF CHECK: -------------------------------------------------- ------------------------------ 1,245.35 ---- THE FOLLOWING IS A DESCRIPTION OF THE EXPLANATION OF BENEFIT (EOB) CODES THAT APPEAR ABOVE: COUNT: 788 DUR REJECT FOR HIGH DOSAGE OR THERAPEUTIC DUPLICATION. 2 ---- THE FOLLOWING IS A DESCRIPTION OF THE ADJUSTMENT REASONS THAT APPEAR ABOVE: COUNT: 20 CLAIM ERROR 1 86 POINT OF SALE TRANSACTION FEE 1

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How to Read Your Remittance Advice Each claim processed during the weekly cycle is listed on the Remittance Advice with the following information:

FIELD NAME

DESCRIPTION

Last, First, and MI

The client's name as found on the EqualityCare ID card.

Client Identification Num

The client's EqualityCare Identification Number.

Trans Control Number

Transaction Control Number: The unique identifying number assigned to each claim submitted.

Amount Billed

Your usual and customary charge

Other Insurance

Any amount paid another insurance

Paid by EqualityCare

The amount paid by EqualityCare

Co-Payment

The amount due from the recipient for their co-payment.

Medical Record Number

Your facilities patient account number

EOB

Explanation of Benefits: A Code, which explains why a service was denied or why payment was reduced. A translation of these codes is included in the final Summary Section of the Remittance Advice.

Line item number and service date

The line item number of the claim and the date the service was provided.

Procedure Code The procedure code and applicable modifier. Units The number of units submitted. Line Billed Amount Your usual and customary line item charge. Performing Provider Number The treating provider number. Pricing Source How the system priced each claim. For example, claims priced manually have a distinct code. Claims paid

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FIELD NAME

DESCRIPTION

according to the EqualityCare fee schedule have another code. Below is a table which translates these pricing source codes:

A = Anesthesia B = Billed Charge C = Percent-of-Charges D = Inpatient Per Diem Rate E = EAC Priced Plus Dispensing Fee F = Fee Schedule G = FMAC Priced Plus Dispensing Fee H = Encounter Rate I = Institutional Care Rate K = Denied L = Maximum Suspend Ceiling M = Manually Priced N = Provider Charge O = Relative Value Units TC P = Prior Authorization Rate R = Relative Value Unit Rate S = Relative Value Unit PC T = Fee Schedule TC X = Medicare Coinsurance and Deductible Y = Fee Schedule PC

Z = Fee Plus Injection Plan The EqualityCare Plan that the recipient is covered under. TTH CD Tooth Code Write Off Amount Amount that provider will need to write off.

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How to Resubmit a Denied Claim

Please check your Remittance Advice before submitting a second request for payment. Claims can be resubmitted for one of the following reasons:

• The claim has not appeared on a Remittance Advice as paid, denied, or pended for thirty days since you submitted it, or

• The claim was denied due to incorrect or missing information. You can resubmit a claim on a new claim form or a legible photocopy after correcting any errors and attaching requested documentation. Claims and attachments, which cannot be clearly microfilmed or photocopied, will be returned. Rebilled claims may be submitted either electronically, via the X12 837 format, or on paper. Adjustments and Refunds

From time to time, you may receive payment for an amount other than billed. Sometimes, you may receive payment from a third party after EqualityCare has made payment. When this happens, submit an adjustment to correct that payment.

• An adjustment is required if an error or change would result in a partial refund. An adjustment is also required if an error or change resulted in an underpayment.

• A cancellation of the entire remittance advice is required if an error would result in complete refund of the entire EqualityCare payment.

Providers will be able to electronically submit adjustments to claims.

Refunding Money to EqualityCare

Return the check issued by EqualityCare only when every claim payment listed on the Remittance Advice is not correct. Example: None of the clients listed are your patients. Return the Remittance Advice and check with a paper Void/Adjustment Request, marking section A, box 2, to:

ACS, Inc. Adjustments P.O. Box 667

Cheyenne, WY 82003-0667

If you receive a Remittance Advice that lists some correct payments and some incorrect payments, do not return the EqualityCare check. Deposit the check and file an adjustment request for each individual claim paid incorrectly.

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General Provider Information August 2003 Incorrectly Billed or Keyed Claims

Since ACS, Inc. processes an adjustment or credit request as a replacement to the original, erroneously paid claim; it is vital that all claim items on the request are completed correctly.

NOTE: Do not just bill for remaining unpaid amounts or units. For example, you submitted and received payment for three units of a procedure and you should have billed for five units. Do not bill for the remaining two units, submit an adjustment for the full five units. If an ACS, Inc. keying error caused the incorrect payment, please contact the Provider Relations Unit. If you were not paid the maximum allowable amount, you are notified on the RA in the "EOB" column as to the reason. All EOB codes are translated at the end of the RA just prior to the Summary Section.

Third Party Recovery After EqualityCare’s Payment

If you discover the liability of another payer after EqualityCare paid you, you MUST submit an adjustment request. How to File a Void or Adjustment Request

Adjustments will not be considered unless submitted on the Adjustment Request Form and all pertinent information is provided. Adjustment requests will not be accepted by telephone. You can correct all errors which occurred on the original claim form with one adjustment request by making changes in red on the claim form and attaching the corrected claim to the adjustment request form. Adjustments and voids are processed as replacement claims. In processing, the original payment is completely deducted and the adjustment is processed as a regular claim. The net result is a transaction that will increase or decrease your check. Provider requested adjustments must be received by ACS, Inc. within six months of the date of payment. Electronic claims billed via X12 837 should be adjusted electronically, WINASAP2003 claims should be adjusted on WINASAP2003 and paper claims should be adjusted on paper.

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VOID/ADJUSTMENT REQUEST FORM

If your claim was DENIED, DO NOT use this form. Please resubmit your claim.

SECTION A: CHECK BOX 1) OR 2)

� 1) CLAIM ADJUSTMENT: Attach claim copy with corrections made in red ink.

DO NOT USE HIGHLIGHTER.

Complete Section B and C.

If attaching a check, the check should be payable to Office of Medicaid.

� 2) CANCELLATION OF THE ENTIRE

REMITTANCE ADVICE. Every claim on the Remittance Advice must be incorrect. This option should only be used in rare instances.

Attach RA and warrant.

Skip to Section C.

SECTION B TO FACILITATE CLAIM ADJUSTMENT PROCESSING, PLEASE COMPLETE THE FOLLOWING:

1. 17-DIGIT TCN:

2. 9-DIGIT PAY-TO-PROVIDER: (OR) 7-DIGIT NABP NUMBER

3. 10-DIGIT PA NUMBER:

4. PROVIDER NAME: 5. 10-DIGIT CLIENT NUMBER:

6. REASON FOR ADJUSTMENT OR VOID:

SECTION C: SIGNATURE AND DATE REQUIRED

PROVIDER SIGNATURE: DATE:

RETURN ALL REQUESTS TO: ACS, INC.

P.O. BOX 667 CHEYENNE, WY 82003-0667

REMARKS/STATUS: (FOR ACS, INC. USE ONLY) CASH CONTROL NUMBER:

ADJUSTED BY: DATE:

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General Provider Information August 2003 How to Complete the Adjustment Request Form

Section

Field #

Field Name

Action

A

1

Claim Adjustment

Mark this box if any adjustments need to be made to a claim. Attach a copy of the claim with corrections made in red ink. Sections B and C must be completed.

2

Cancellation of the Entire Remittance Advice

Mark this box if an error or change would result in complete refund of the EqualityCare payment. Attach a copy of the Remittance Advice and the warrant. Every claim on the Remittance Advice must be incorrect. This option should only be used in rare instances. (Skip to Section C)

B

1

17-digit TCN

Enter the 17-digit transaction control number assigned to each claim from the remittance advice (RA).

2

9-digit Pay-To-Provider Number

Enter your 9-digit EqualityCare provider number if applicable.

3

10-digit PA Number

Enter your 10-digit EqualityCare PA number if applicable.

4

Provider Name

Enter your provider name.

5

10-digit Client Number

Enter the 10-digit EqualityCare Client ID number.

6

Reason for Adjustment

Enter the specific reason for this adjustment and any pertinent information to assist ACS, Inc. in processing this adjustment.

C

Provider Signature and Date

Signature of the provider or the provider's authorized representative and the date.

Adjusted By:

Do not write in this section. To be completed by ACS, Inc.

Send the Adjustment Request to:

ACS, Inc. Adjustments P.O. Box 667

Cheyenne, WY 82001

7-29

General Provider Information August 2003 Timely Filing Timely Filing Criteria

The Office of Medicaid adheres strictly to the timely filing policy. You must submit a clean claim to ACS, Inc. within twelve months of the date of service. A clean claim is an original, correctly completed claim that will process and approve to pay in the twelve-month time period. Submit claims immediately after providing services so that if a claim is denied, you have time to correct any errors and resubmit. Be sure that ACS, Inc. receives a clean claim within the twelve-month deadline. Exceptions to the Twelve-Month Limit

Exceptions to the twelve-month claim submission limit can be made under certain circumstances. The chart below shows when an exception can be made, the time limit for each exception, and how to request an exception.

Exceptions Beyond the Control of the Provider

When the situation is: The time limit is:

Medicare Crossover A claim must be submitted within one year of the date of service or within six months from payment / denial on the Medicare EOMB whichever is later.

Client is determined to be eligible on appeal, reconsideration, or court decision.

There is no timely filing limit. HOWEVER, if a claim exceeds timely filing, a copy of the notice must be attached to the claim with a cover letter requesting an exception to timely filing.

Client is determined to be eligible due to agency corrective actions.

There is no timely filing limit. HOWEVER, if a claim exceeds timely filing, a copy of the notice must be attached to the claim with a cover letter requesting an exception to timely filing.

The notice of retroactive eligibility may be a SSI award notice or a notice from DFS. Appeal of Timely Filing

A provider may appeal a denial for timely filing ONLY under the following circumstances: • The claim was originally filed within twelve months of the date of service; and • The provider made at least one attempt to refile the claim within 12 months of the date of

service; or • An EqualityCare computer or policy problem beyond the providers control prevented the

provider from finalizing the claim within twelve months of the date of service. Any appeal that does not meet the above criteria must be denied. Timely filing cannot be waived when a claim is denied due to provider billing errors. Timely filing cannot be waived in cases involving third party liability.

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General Provider Information August 2003 How to Appeal

The provider should appeal directly to ACS, Inc. and should include the following: • Documentation of previous claim submission; • An explanation of the problem; and • A clean copy of the claim, along with any required attachments.

Important Information Regarding Retroactive Eligibility Decisions

• The client is responsible for notifying the provider of the retroactive eligibility determination and supplying a copy of the notice to the provider.

• A provider is responsible for billing EqualityCare only if: They agreed to accept the patient as an EqualityCare client pending

EqualityCare eligibility; or After being informed of retroactive eligibility they elect to bill EqualityCare for

services provided previously under a private payment agreement. In this case any money paid by the patient would need to be refunded prior to a claim being submitted to EqualityCare.

NOTE: Inpatient Hospital Certification: A special review may be required to obtain

certification for an inpatient hospital stay, which occurred during the period covered by a retroactive eligibility determination.

Failure of Eligible Client to Notify Provider of EqualityCare Eligibility

If a client who is EqualityCare eligible at the time of service fails to notify a provider that they have EqualityCare benefits and is billed as a private pay patient, the client is responsible for the bill unless the provider agrees to discontinue billing the client and to submit a claim to EqualityCare. In this case:

• Any money paid by the client must be refunded prior to billing EqualityCare; and • The client can no longer be billed for the service; and • Timely filing criteria is in effect.

Billing Tips to Avoid Timely Filing Denials

• File claims as soon as possible after service takes place. • Carefully review error denial codes on the Remittance Advice including detail denial

lines and additional errors reported beneath each claim. • Resubmit the entire claim or denied detail line after all corrections have been made. • Prior to resubmitting a claim, contact ACS, Inc. if you have any questions regarding billing

or denials. • If you have not received payment within forty-five days of submission, contact ACS, Inc.

regarding the status of the claim. • If you have had multiple denials on a claim, contact ACS, Inc. and request a review of the

denials prior to resubmission.

NOTE: Once a provider has agreed to accept an EqualityCare patient, any loss of EqualityCare reimbursement due to provider failure to meet timely filing deadlines is the responsibility of the provider.

Filing Deadlines for Adjustments

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EqualityCare accepts adjustment requests for underpayments submitted to ACS, Inc. within six months of the paid date of the original claim. Adjustment requests for overpayments are accepted indefinitely. Please note, however, that the EqualityCare Provider Agreement requires you to notify EqualityCare within thirty days of learning of an excess payment. Refund checks are not encouraged, as a more timely internal deduction is processed with your next payment. If EqualityCare determines during a claims review that an excess payment has been made, you are notified in writing of the error and given the option of refunding the excess payment or having it deducted from a future payment within thirty days from date of the notice. It is more time effective if it is deducted from a future payment.

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Chapter Eight Third Party Liability

What Is Third Party Liability (TPL)? .................................................................................... 8-2 How To Identify TPL............................................................................................................. 8-2 How to Bill Third Party Payers ............................................................................................. 8-3 What are the exceptions to Third Party Billing? ................................................................... 8-4

When the services are for Preventive Pediatric Care................................................. 8-4 When the services are related to Prenatal Care.......................................................... 8-4 When the policy holder of the other insurance is an absent parent ........................... 8-4 When legal liability has not been established............................................................ 8-5

Questions about TPL ............................................................................................................ 8-5 Why should I care about TPL? .................................................................................. 8-5 Who pays the bill when a client has other insurance? ............................................... 8-5 Can I refuse to accept EqualityCare patients with other insurance if my

Office doesn't bill other insurance? .............................................................. 8-6 When can I bill a client? ............................................................................................ 8-6

Wyoming Health Insurance Premium Payment Program...................................................... 8-7 What is WHIPP? ....................................................................................................... 8-7 Benefits to clients ...................................................................................................... 8-7 Benefits for all Wyoming residents ........................................................................... 8-7 What will EqualityCare cover under the WHIPP program? ..................................... 8-7 What clients must do to enroll in WHIPP? ............................................................... 8-8

Previous Billing Attempts Letter ........................................................................................... 8-9 Third Party Resources Information Sheet............................................................................ 8-10 Health Insurance Verification Form .................................................................................... 8-11 WY Health Insurance Premium Payment Statement ........................................................... 8-12 Health Insurance Premium Payment Medical History Questionnaire ................................. 8-13

8-1


What is Third Party Liability (TPL)?

A third party is defined as “…a person, entity, agency, or government program that may be liable to pay, or that pays all or part of the costs of services provided to a recipient. ‘Third party payer’ includes but is not limited to, insurance companies, workers’ compensation, defendants or potential defendants in legal actions involving recipients or an individual or entity acting on behalf of a recipient, a spouse or parent who is obligated by law or court order to pay all or part of such costs, or a recipient’s estate…” as per the Wyoming Department of Health, Wyoming Medicaid Rules, Medical Benefit Recovery, Section 4(qq).

How to Identify TPL

Information about third party coverage is available through the eligibility verification systems. If the client shows you a different proof of eligibility, you must ask if the client is covered by other insurance that might help to pay for your services. EqualityCare is always payer of last resort except for 100 percent federally funded programs such as Indian Health Services and the Ryan White Foundation,. You must bill all other potential payers before billing EqualityCare. Call the Automated Voice Response locally at 772-8403 or 1-800-251-1270 using the client's Social Security number and date of birth or Client Identification number and date of birth for access. You will receive not only current eligibility information, but also information concerning Medicare or other insurance coverage. You can also ask ACS, Inc. if another insurance company covers your patient. Call ACS, Inc. locally at 772-8401 or toll free outside Cheyenne at 1-800-251-1268.

8-2


How to Bill Third Party Payers

If the client has health insurance that may cover or partially cover the services you plan to provide, please take the following steps.

STEP ACTION 1 Locate the potential payer's address and phone number. If your EqualityCare claim was denied

because of other insurance coverage, the address will appear on the Remittance Advice (RA). 2 Contact the other insurance carrier by telephone if possible.

• If the coverage is expired or not applicable, ask the company to send you a denial letter. If they refuse, write down the contact person's name, telephone number, date of phone call, and nature of information provided.

• If the coverage does apply, ask if prior authorization is required. • Skip to step 4 if some payment seems likely.

3 • If you receive a denial letter from the other payer, attach it to your claim and submit it to ACS, Inc. just as you would your other claims.

• If you prefer, or if the other carrier advises, file a claim with the other carrier even if the services will be denied. You will then receive an official denial form from them, which you can attach to your claim and used for one calendar year.

• If you receive a verbal denial, type a letter of explanation on your office letterhead. Summarize what you were told. List the date of denial, the payer's name and the contact person's name and telephone number. Attach this letter to your claim and submit to ACS, Inc. Include recipients ID number, name and date of service.

• If the insurance carrier does not respond within ninety days, submit the claim to EqualityCare with the documentation of two attempts to bill attached. EqualityCare will then pay up to the EqualityCare allowable. See Exhibit 8.1 for sample documentation of two billing attempts.

4 When you receive payment from another carrier, compare the amount received per procedure code with EqualityCare’s maximum fee for the same procedure code.

• If the payment from the other payer is less than EqualityCare’s maximum payment for a procedure, indicate the payment in the appropriate box on the claim form and attach a copy of the documentation.

• If the insurance paid more than forty percent of the total bill per claim, you do not have to attach a copy of the Explanation of Benefits from the insurance company. You can submit the claim electronically referencing the amount paid by the other party.

• When EqualityCare has paid and another insurance subsequently pays, you must refund the EqualityCare payment through an adjustment request for either the amount of the EqualityCare payment or the amount of the insurance payment, whichever is less. You must include a copy of the EOB form the other payer showing the reimbursement amount.

5 Attach a copy of the other carrier's EOMB to your claim and submit to ACS, Inc. 6 Let us know before timely filing becomes a problem if for some reason this requirement is

difficult to fulfill.

NOTE: Waivers of timely filing will not be given because of third party liability.

8-3


Electronic COB You will be able to submit electronic COB (coordination of benefits information) as a part of the 837 transaction. The COB information must be complete and indicate who the payer is, payment date, and what the amount of payment is. You will be able to send paper attachments to show denial/payment of TPL to accompany an electronic claim. Please refer to Chapter 7 for Claim Paper Attachment information. Exceptions to Third Party Billing

There are four circumstances when you do not have to bill other health insurance before billing EqualityCare. They are:

• When the services are for Preventive Pediatric Care Preventive Pediatric Care is officially defined as screening and diagnostic service to identify congenital physical or mental disorders, routine examinations performed in the absence of complaints, and screening or treatment designed to avert various infections and communicable diseases from occurring in children under age 21. This includes immunizations, screening tests for congenital disorders, well child visits, preventive medicine visits, preventive dental care, and screening and preventive treatment for infectious and communicable diseases. Diagnosis codes include V01-V07, V20, V70, and V72.0-V82. These are all inclusive unless otherwise stated.

• When the services are related to Prenatal Care Prenatal Care is officially defined as services provided to pregnant women if such services relate to the pregnancy or to any other medical condition, which may complicate the pregnancy. The types of claims involved are those for routine prenatal care, prenatal screening of mother or fetus, and care provided in the prenatal period to the mother for complications of pregnancy. Diagnosis codes include V22-V23, V28, 640-659, 671, 673, and 675-676. These are all inclusive unless otherwise stated.

NOTE: Other insurance must be billed first for claims associated with the inpatient

hospital stay for labor and delivery, and post-partum care. • When the policy holder of the other insurance is an absent parent

The absent parent's obligation to provide medical support must be court ordered and EqualityCare must have a copy of the court order on file. If you choose to bill the other insurance prior to billing EqualityCare, you cannot bill EqualityCare within thirty days of the date of service. You must certify on an attachment to the claim that a third party has been billed and that thirty days has elapsed from the date of service without payment from the third party.

8-4


• When legal liability has not been established

If there is auto, homeowners, or other casualty insurance, which may cover medical expenses associated with an accident, you do not have to bill the carrier until the carrier accepts responsibility for the claims. If you believe there may be casualty insurance LET US KNOW at 772-8401 or 1-800-251-1268 outside Cheyenne calling area. The TPL unit will investigate and advise you if the other insurance will pay claims. Since this type of insurance often pays 100 percent of billed charges, you may choose to wait for legal liability to be established before billing the other insurance, but keep in mind that EqualityCare will not pay claims more than a year old. If legal action is pending, you can submit claims to EqualityCare for payment pending establishment of legal liability through judgment or settlement.

Questions about TPL Why should I care about TPL?

EqualityCare is considered the payer of last resort. Before the program can pay you, you must bill all third parties, which might help to pay for the services you provided. This shifts the payment of medical services to the legally liable private sector reducing the burden on taxpayers. If EqualityCare has a record of other insurance coverage for the client, you must bill (or contact) the other carrier first. If you do not bill the other carrier first, ACS, Inc. denies your claim. On the Remittance Advice, ACS, Inc. gives you the name, address, and policy number so that you can bill the third party before resubmitting your claim. Finding out about other insurance up front will save you the time and expense of billing (and being denied by) EqualityCare when there is other insurance that must be billed first. If you have any problems getting the information needed to bill, need information verified with an insurance carrier, or have any questions or problems regarding TPL, call the ACS, Inc. TPL unit at 772-8401 or 1-800-251-1268 outside Cheyenne. Call the TPL Unit:

• If you find that a policy is no longer in effect; (We will not require the policy be billed if it has expired.)

• If you know of new insurance coverage; • If a client has been in an accident which may be covered by liability or casualty insurance

or legal liability is being pursued; or • If you receive a request for medical information from insurance companies, attorneys, or

other third parties.

Who pays the bill when a client has other insurance?

EqualityCare is payer of last resort. Once a third party's legal liability has been established, any claims must first be filed with them. After the third party has either paid or denied the claim, you can submit the claim for payment with documentation of payment, denial or attempt to bill. The client cannot be billed. You cannot bill the client for the co-pay and deductible. If you have accepted partial payment from a client before they became eligible and you chose to accept them

8-5


as an EqualityCare client you must refund any payments received from the patient. Can I refuse to accept EqualityCare patients with other insurance if my office doesn't bill other insurance?

A provider cannot refuse to see a client because he/she has other insurance. A practitioner may limit the number of EqualityCare patients he/she is willing to admit in his/her practice. The practitioner may not discriminate in establishing the limit. 42 (Code of Federal Regulations) C.F.R. 447.20 states:

A provider may not refuse to furnish services covered under the plan to an individual who is eligible for Medical Assistance under the plan on account of a third party's potential liability for the service(s).

When can I bill a client?

You may bill a client when: • The client has exceeded the EqualityCare limits on prescriptions, office, outpatient

hospital, and physical therapy visits. You can call the AVR to determine this information. • The services you are providing are not covered by EqualityCare or are not medically

necessary or cost effective and you have explained this to the client and mutually agree in writing before rendering services.

• If the client is not EqualityCare eligible at the time you provide the services, or they are not on a program that covers those particular services.

You may not bill a client:

• When you do not receive an answer from an insurance company. It is your responsibility to bill and follow up with the insurance company. EqualityCare makes allowances for those times when you do not receive notification from the insurance company.

• When the client presents an EqualityCare Client ID card and you accept them as a patient. Once you accept a client as an EqualityCare patient, bill the insurance carrier and then EqualityCare.

• When you bill EqualityCare for a covered service, and EqualityCare denies your claim because of billing errors you made (such as wrong procedure and diagnosis codes, lack of prior authorization, invalid consent forms, unattached necessary documentation, incorrectly filled out claim form, etc).

• When EqualityCare denies your claim and another third party insurer has paid up to or exceeded what EqualityCare would have paid.

• For the difference in your charges and the amount EqualityCare has paid. • For a service for which you have billed EqualityCare.

You may not require a client to pay before rendering services except the co-pay amount. You may not bill a client for charges in excess of payment. EqualityCare payment is payment in full.

We Need Your Help

When TPL is at its best, everybody wins. EqualityCare saves money without denying access to quality health care, which may forestall reductions in provider reimbursement rates. Providers are given information on other payers who may pay at a higher rate than EqualityCare. Please fulfill all requirements for notifying ACS, Inc. of any insurance information you have by providing us with a copy of the completed Third Party Resources Information Sheet (See Exhibit 8.2) or by calling 772-8401 or 1-800-251-1268 outside the Cheyenne calling area.

8-6


Wyoming Health Insurance Premium Payment Program What is WHIPP?

The Social Security Act (section 1902-1906) allows Wyoming to pay private health insurance premiums for EqualityCare/Medicaid clients to keep their private health insurance whenever it is cost effective to do so. Cost effectiveness means the cost of the insurance premiums; co-insurance and deductibles are less than what EqualityCare would pay without the client's insurance coverage. EqualityCare continues to pay the cost effective private health insurance during the time clients are eligible for EqualityCare. Benefits to Clients

There are several reasons why having insurance may be helpful to clients: • A private health insurance policy may cover services that may not be covered by

EqualityCare. • If clients maintain their private health insurance during an EqualityCare eligible period,

re-enrollment in the private insurance is not necessary after clients are no longer eligible for the EqualityCare program.

• Members of a client's family who are not eligible for EqualityCare will be covered under the private health insurance plan when EqualityCare decides that buying a family plan for the EqualityCare eligible person is cost effective.

Benefits for all Wyoming Residents

The Health Insurance Premium Payment Program benefits all Wyoming residents by helping to control EqualityCare costs. What will EqualityCare cover under the WHIPP program?

If EqualityCare decides that the group health insurance available to a client through his or her employer is cost effective, the client must participate in the plan as a condition of EqualityCare eligibility. If the client drops the insurance coverage or fails to provide employer insurance information needed to determine cost effectiveness, the client's EqualityCare benefits will be canceled. Participation through private health insurance is not mandatory. EqualityCare will make arrangements to pay the health insurance premiums directly to the insurance carrier. If it is a payroll deduction, EqualityCare will ask the employer to agree to accept payment from the client's earnings. If the employer will not agree, EqualityCare will reimburse the client directly for the payroll deduction made after the client submits to EqualityCare proof of insurance payment. Claims from medical providers for persons participating in this program will be paid in the same manner as claims paid for other clients with a third-party resource in accordance with EqualityCare program guidelines.

8-7


What must clients do to enroll in WHIPP?

As part of a client's current and ongoing eligibility for EqualityCare, he/she must meet the following requirements:

• For any non-employment and employment related insurance, complete the Health Insurance Verification Form and the Health Insurance Premium Payment Medical History Questionnaire (see Exhibit 8.5).

• Submit the WHIPP Program Application Form with all other attachments to the DFS Eligibility Specialist. Please advise clients to include any estimates that they can reasonably make concerning future medical expenditures.

• Continue to pay the premium for the health insurance until they receive notification concerning their eligibility for WHIPP from the EqualityCare agency.

• EqualityCare will verify the insurance information, obtain premium amounts, and make the cost effectiveness determination. The DFS Case Worker will be notified within forty-five days from the day of receipt of the application whether clients are eligible for the Health Insurance Premium Payment Program.

• Questions concerning this program can be directed to ACS, Inc. at (307) 772-8401.

8-8


EXHIBIT 8.1 Previous Attempts to Bill Services Letter

September 5, 2003

Dear EqualityCare, This letter is to request the submission of the attached claim for payment. As of this date, we have made two attempts within ninety days of service to gain payment for the services rendered from the primary insurance with no resolution. We are now requesting payment in full from EqualityCare. Please find all relevant and required documentation attached. Thank you.

Sincerely,

Authorized Representative of (Billing Facility)

Name of Insurance Company billed: Date billing attempts made: Policyholder’s name: Policyholder’s policy number: Comments:

P.O. Box 667 Cheyenne, WY 82003307.772.8400 307.772.8405 (fax)

8-9


EXHIBIT 8.2 THIRD PARTY RESOURCES INFORMATION SHEET

THIRD PARTY RESOURCES INFORMATION SHEET

NEW CHANGE

1. CLIENT NAME:

2. CLIENT ID NUMBER:

3. INSURANCE COMPANY NAME:

4. INSURANCE COMPANY ADDRESS:

5. TYPE OF COVERAGE:

____ Major Medical ____ Physician ____ Hospital ____ Prescription Drugs ____ Surgical ____ Other

6. PERSON CARRYING THE POLICY:

7. START DATE (MM/DD/YY):

8. END DATE (MM/DD/YY):

9. POLICY NUMBER:

10. GROUP NUMBER

11. RELATIONSHIP OF CLIENT TO CASE HEAD: _____Self (1) _____ Absent Parent (2) _____ Other (3) _____ Parent (4) _____ Spouse (5) _____Brother/Sister (6) _____ Uncle/Aunt (7) _____ Grandparent (8) _____ Legal Guardian (9) 12. NAME OF PROVIDER: 13. COMPLETED BY:

14. DATE SUBMITTED:

RETURN TO ACS, INC. P.O. BOX 547 CHEYENNE, WYOMING 82003-0547

FAX: (307) 772-8405

ACS, INC. USE ONLY AUTHORIZED BY:_____________________ DATE:______________ INPUT BY:____________________________ DATE:______________

8-10


EXHIBIT 8.3 HEALTH INSURANCE VERIFICATION FORM

EQUALITYCARE APPLICANT: S.S.N. Client ID: Case Number: Phone:

Address: City: State: Zip:

Do any EqualityCare clients in your household have a health insurance coverage plan and if so do they meet one or more of the following criteria:

Medical bills over the past six months exceeding the amount of monthly premiums. Attach bills you have paid or insurance explanation of benefits.

Temporary disability or other condition, as determined by a medical professional and expect to require continuous care for a period of more than six months.

YES: NO: If yes, complete and return this form to your caseworker. Attach a plan of treatment from your health care provider and proof of any insurance payments for the last six months. Failure to do so could affect your eligibility for EqualityCare. If no, stop and return this form to your caseworker.

I hereby authorize my insurance carrier named below to furnish the Wyoming Department of Health, Office of Medicaid any confidential information requested regarding my insurance coverage and any reimbursement for payments made by EqualityCare. I hereby forever release and discharge my insurance carrier from any liability for divulging such information; notwithstanding the fact this authorization expires upon termination of EqualityCare eligibility. Signature Date

Health Insurance Information

Policy holder’s name: S.S.N. - - Address: City: State: Zip: Phone: Relationship to clients: Policy number Group number ______________ Effective date of policy Termination date of policy____________________ Name of insurance company: Phone: _______________ Address: City: State: Zip: Is this an employment related health insurance plan? Yes: No: _____ Circle all services covered under your policy Accident Ambulance Casualty Champus Dental Disease Doctor Drug HMO Hospital Major Medical Nursing Home US Public Health Veteran’s Administration Supplement Specify other coverage: ___________________________________

Plan type : Family Single Premium per ______ Deductible : per Co-insurance : % / % Other: Persons covered under this policy

Name Date of Birth SSN Client ID / / - - 06 / / - - 06 / / - - 06 / / - - 06 / / - - 06 / / - - 06

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EXHIBIT 8.4 WYOMING HEALTH INSURANCE PREMIUM PAYMENT HCF-WHIPP 1a

EMPLOYER'S/INSURANCE STATEMENT Worker County

I hereby authorize my employer/former employer or insurance carrier named below to furnish the Wyoming Department of Health, Division of Health Care Financing any confidential information requested regarding my employment or insurance coverage. I hereby forever release and discharge my employer/former employer or insurance carrier from any liability for divulging such information, notwithstanding the fact this authorization expires upon termination of Medicaid eligibility. Employee Name

I

SSN

Signature Date

Employer Name

Address

City

State

Zip

HEALTH INSURANCE INFORMATION

Number of employees in company?________________ Name/Address of Carrier

Do you offer health insurance? Yes No

If no, STOP HERE. If yes, complete the following:

Who is eligible for coverage? Employee Dependents Names

Insured/Policy Holder

Policy Number

Effective date of policy for

What is the cost to the employee, if any for premiums?

Single plan__________________ Family plan_________________

Coverage (mark all that apply) $_________________single plan $_______________family plan

Hospital

Physician

Surgical

Major Medical

Accident

weekly biweekly monthly semimonthly other_______

Indemnity

Dental

Vision

Pharmacy

Supplement

The date payroll deduction for insurance began or will begin (date check was received):

Auto

Hospital

Disease

Nursing Home

HMO

___________________

Other (please specify):

Is employee currently enrolled? Dependents? Yes No

Yes No

Group Name

Group Number

Will the employer accept payment from the Division of Health Care Financing for premium in lieu of a payroll deduction to the employee's wages?

Yes No If YES, enter employer federal tax ID# and address where premium payments should be mailed: fed id#________________

Address:______________ _____________________ _____________________

Is there a waiting period before employee can enroll in the health plan? Yes No If yes, date employee is eligible to enroll?________________

Comments

Authorized Rep. Signature

Title

Phone #

Date

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EXHIBIT 8.5 Wyoming Office of Medicaid HCF-WHIPP 1b

147 Hathaway Building 2300 Capitol Ave.

Cheyenne, WY 82002

HEALTH INSURANCE PREMIUM PAYMENT MEDICAL HISTORY QUESTIONNAIRE

1. How many prescriptions are filled each month for the Medicaid clients in your household who are covered under

this insurance policy? Average monthly cost? $ 2. Are any of the Medicaid clients covered under this policy periodically institutionalized or currently living in an

institution (mental institution, nursing home or hospital, etc)? Yes No If yes, list name of client and the reason he/she is institutionalized .

3. Check all following conditions that apply to any Medicaid client covered under this policy. List the name of the

person with each condition and how often medical care is needed to treat the condition.

Condition

Yes

If yes, name of person with condition

How often is medical care require?

Diabetes

Blood Disorder

Cancer

Mental Illness / Retardation

Pregnancy

Due Date?

Heart Condition

Asthma / Respiratory Ailment

Scoliosis / Back Injury

Stroke / Head Injury

Organ Transplant

Seizure Disorder

HIV Positive / Acquired Immune Deficiency (AIDS)

Alcoholism / Drug Addiction

List other Disease Condition

4. Are any of the conditions checked “Yes” above excluded from coverage under this health insurance plan as a pre-

existing medical condition? Yes No _________ If yes, list conditions not covered.

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Chapter Nine HIPAA Introduction

HIPAA Introduction...............................................................................................................9-2 Implementation Dates ............................................................................................................9-3 Claims Submission.................................................................................................................9-3 Glossary of HIPAA Transactions ..........................................................................................9-4 Submitting Claims Electronically ..........................................................................................9-4 Pharmacies and HIPAA .........................................................................................................9-5 Number of Lines ....................................................................................................................9-5 Prior Authorization ................................................................................................................9-5 Paper Attachments .................................................................................................................9-6 Nursing Facility Claims .........................................................................................................9-6 Local Codes and Modifiers....................................................................................................9-6 Adjustments ...........................................................................................................................9-6 Remittance Advices ...............................................................................................................9-6 Checking Status of a Claim....................................................................................................9-7 Checking Client Eligibility ....................................................................................................9-7 Additional Information Sources.............................................................................................9-8

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HIPAA Introduction

The Health Insurance Portability and Accountability Act (HIPAA) of 1996 was passed to improve portability and continuity of health insurance coverage in the group and individual markets, to combat waste, fraud, and abuse in health insurance and health care delivery, to promote the use of medical savings accounts, to improve access to long-term care services and coverage, and to simplify the administration of health insurance. The goal is to protect individual’s privacy as was as make billing easier and more universal for all providers, for all health plans. EqualityCare and ACS have worked for two years to minimize the impact of HIPAA on providers and to prepare providers for all changes. This chapter explains how EqualityCare intends to meet the federal HIPAA requirements on electronic transactions and code sets. The information applies specifically to the EqualityCare programs, all of which are administered by the Department of Health. This chapter will not explain the HIPAA guidelines themselves or advise providers on how to meet the guidelines, but will explain the changes to billing procedures.

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General HIPAA Points The HIPAA changes affect how providers and EqualityCare will communicate with each other electronically. EqualityCare is not changing its policies on paper claims submission, prior authorization or eligibility verification. Though the information in this document is subject to change, EqualityCare understands that providers need as much certainty as possible in planning for HIPAA implementation. Providers should periodically check for updates on the EqualityCare Website at: wyequalitycare.acs-inc.com Implementation Dates HIPAA mandates compliance by October 16, 2003, if the state filed for and was approved for an extension to the October 16, 2002 deadline. However, ACS will be ready and processing HIPAA transactions on September 29, 2003. Claims Submission Providers may use one or more methods for electronically submitting claims and receiving data. The methods listed below will help determine provider’s data submission options.

• Dial-up Using WINASAP2003 WINASAP2003 is available free to providers from ACS EDI Gateway. No Internet access is needed. WINASAP2003 will replace ACE$. Please see Chapter Five in the General Provider Manual for more information.

• Dial-up Using Other Software Providers may also use other software not provided by ACS EDI Gateway to submit batches of claims via ordinary phone lines.

• Clearinghouse A clearinghouse is a company that accepts claims from a provider and routes them to fiscal agents and other payers.

• Billing Agent A billing agent is a company that acts as a third party to providers, actually billing or entering the electronic claims on behalf of the providers.

* Providers will still have the option of billing on paper. The claim forms that will be accepted by Wyoming EqualityCare are the CMS-1500, UB92, ADA 2002, and the Universal Pharmacy claim form.

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Glossary of HIPAA Transactions X12 270- The X12 Health Care Eligibility & Benefit Inquiry transaction. X12 271- The X12 Health Care Eligibility & Benefit Response transaction. X12 276- The X12 Health Care Claims Status Inquiry transaction. X12 277- The X12 Health Care Claim Status Response transaction. X12 278- The X12 Referral Certification and Authorization transaction. X12 820- The X12 Payment Order & Remittance Advice transaction. X12 824- The X12 Error Report transaction. X12 835- The X12 Health Care Claim Payment & Remittance Advice transaction. X12 837- The X12 Health Care Claim or Encounter transaction. X12 997- The X12 Functional Acknowledgement transaction. Submitting Claims Electronically When a provider submits their claims electronically to ACS, the claims must be in the X12 837 format.

1. They will be able to do this by using a dial-up connection to bill via WINASAP2003. WINASAP2003 software will replace ACE$ and will still be free of charge.

2. Providers can also contract with a clearinghouse so that they can send the claim to the clearinghouse in whatever format the clearinghouse accepts. The provider’s clearinghouse would then send the claim to the ACS clearinghouse in the X12 837 format.

3. Other Software. 4. Billing Agent.

The new field software, WINASAP2003, will replace ACE$. The new software can be used to submit claims only for Wyoming EqualityCare programs. It will not support submissions to Medicare or other payers. This software will create an 837-like transaction.

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Pharmacies and HIPAA With the exception of remittance advices, the X12 transactions do not apply to pharmacies. Under HIPAA, the standard for pharmacy claims submission will be NCPDP 5.1 rather than NCPDP 3.2. EqualityCare will continue to accept only NCPDP 3.2 until September 29, 2003. Pharmacies can continue to submit claims on paper, using the Universal Claim Form. Unlike ACE$, the new WINASAP2003 software will not have the capability of creating a pharmacy claim. Number of Lines Providers will be able to submit electronic claims that include the maximum number of lines specified in the X12 837 implementation guidelines. Since these maximums are greater than the maximums currently used, EqualityCare will implement procedures for special processing of these claims. EqualityCare strongly encourages providers to stay within the current maximum guidelines: UB92 - Institutional Claim 100 lines CMS-1500 - Professional Claim 50 lines ADA2002 – Dental Claim 50 lines Prior Authorization Under the X12 837 transaction, providers can list PA numbers at the line level, so that the potential exists for two or more distinct PA numbers on the same claim. Providers will have three ways to request and receive Prior Authorization: through the paper process, or through the X12 278 transactions. 1. Paper Process - In order to request Prior Authorization, providers can continue to

call the authorizing agency (CFMC or ACS), submit PA information by fax, mail or receive a pending authorization by phone.

Once the PA request has been reviewed, it will be approved, denied, or pended, and a PA letter will be sent communicating the information.

2. X12 278 Transaction - If a provider requests a PA using the X12 278 format, they

will receive the authorization itself from ACS electronically in the X12 278 format. 3. X12 278 Transaction - Web based – Currently not avaible.

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Paper Attachments Providers will be able to choose to submit electronic claims with paper attachments. ACS will institute a process to match up electronic claims with the appropriate paper attachment. Nursing Facility Claims Nursing facilities can electronically submit the X12 837 transactions using ACS proprietary software. EqualityCare will no longer accept the Turn Around Document (TAD) as of September 29, 2003. Local Codes EqualityCare will no longer accept local codes and modifiers. These are most heavily used by mental health, durable medical equipment, and home and community-based waiver programs. Please refer to the Covered Services Manuals for the Cross Walk Codes that will take the place of these local codes and modifiers. Modifiers EqualityCare will accept up to four modifiers per line on X12 837 institutional (UB92) and professional (CMS-1500) claims as shown in the X12 implementation guides. Adjustments Providers will be able to electronically submit adjustments to their electronically submitted claims. However, if the claim was submitted on paper, the adjustment must also be submitted on paper. Please refer to the General Provider Manual Chapter 7 for the appropriate Void/Adjustment form. Remittance Advices ACS will create an automatic X12 835 transaction to any provider who submits an X12 837 transaction. A paper RA will also be produced. Electronic RA’s will show the standard claim adjustment reason and payment remark codes (the same as Medicare and other payers) rather than the EqualityCare specific explanation of benefits (EOB) codes. Paper remittance advices continue to provide the specific denial codes.

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Checking Status of a Claim Providers will have three ways to check whether a specific claim or set of claims has been paid, denied, or pended. 1. X12 276/277 Transaction - Providers will be able to send X12 276 claims inquiry

transactions to ACS, and ACS will send back the X12 277 response in batch mode. 2. Provider Relations - Providers will continue to be able to check claims status with

Provider Relations, either by calling Provider Relations or by submitting a claims inquiry form by mail or fax.

3. ACS Mevsnet.com (1-800-333-4979) - Provides an Internet-based verification for

EqualityCare, KidCare and other Wyoming Department of Health programs. There is a monthly cost plus a transaction fee. Installation includes a swipe card reader that attaches to an existing computer and requires a modem and Internet connection through a dial-up Internet Service Provider.

Checking Client Eligibility Providers will have four ways to verify eligibility of EqualityCare clients. 1. X12 270/271 Transaction - Providers will be able to send an X12 270 eligibility

transaction to ACS, and ACS will send back the X12 271 response in batch mode. 2. Automated Voice Response System (AVRS) - HIPAA does not require any changes

to the AVR system. 3. Provider Relations - Providers can continue to call Provider Relations at 1-800-251-

1268 or (307) 772-8401. 4. Eligibility Vendors - Medifax and ACS Mevsnet.com. - EqualityCare has an

agreement with these vendors under which subscribers can check EqualityCare eligibility. Medifax and ACS Mevsnet.com do require a fee.

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Additional Information Sources For more information regarding HIPAA, please refer to the following websites. Centers for Medicare and Medicaid Services: www.cms.gov/hipaa/hipaa2/default.asp. This is the official HIPAA website of the Centers for Medicare & Medicaid Services (formerly HCFA). Washington Publishing Co.: www.wpc-edi.com/hipaa/HIPAA_40.asp. This website is the official source of the implementation guides for each of the X12 transactions mandated by HIPAA. Workgroup for Electronic Data Interchange: www.wedi.org. This industry group promotes electronic transactions in the health care industry. See especially its snip.wedi.org (no www) webpage, which focuses on implementing HIPAA changes. Designated standard maintenance organizations: www.hipaa-dsmo.org. This website explains how changes are made to the HIPAA standards. National Council for Prescription Drug Programs: www.ncpdp.org. This website explains the NCPDP standards for pharmacy transactions. ACS Prescription Benefits Management Services-HIPAA Overview: www.acspbmhipaa.com. American Dental Association (ADA) HIPAA Information: www.ada.org/prof/prac/issues/topics/hipaa/. American Hospital Association (AHA) HIPAA Information: www.hospitalconnect.com/aha/key_issues/hipaa/index.html. American Medical Association (AMA) HIPAA Information: search.ama-assn.org/Search/query.html?qc=public+pubs+amnews&qt=hipaa. Glossary of HIPAA Terminology: www.wedi.org/snip/public/articles/HIPAA_GLOSSARY.PDF. HIPAA Administrative Simplification: cms.hhs.gov/hipaa/hipaa2/default.asp. HIPAA Advisory Website: www.hipaadvisory.com/. Office of Civil Rights (OCR) Privacy Rule Website: www.hhs.gov/ocr/hipaa/.

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http://www.cms.gov/hipaa/hipaa2/default.asp

http://www.wpc-edi.com/hipaa/HIPAA_40.asp

http://www.wedi.org/

http://www.hipaa-dsmo.org/

http://www.hipaa-dsmo.org/

http://www.ncpdp.org/

http://www.acspbmhipaa.com/

http://www.ada.org/prof/prac/issues/topics/hipaa/

http://www.hospitalconnect.com/aha/key_issues/hipaa/index.html

http://www.wedi.org/snip/public/articles/HIPAA_GLOSSARY.PDF

http://www.hipaadvisory.com/

http://www.hhs.gov/ocr/hipaa/

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