HP Provider Relations October 2011 HCBS Waiver Program Guidelines and Billing.

HP Provider RelationsOctober 2011

HCBS Waiver Program

Guidelines and Billing

HCBS Waiver Program Guidelines and BillingOctober 2011

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Agenda– Objectives

– Overview of the Home and Community-Based Services (HCBS) Medicaid Waiver Program

– Member Eligibility

– Billing

– Electronic Claim Filing

– Paper Claim Filing Hints

– Remittance Advice

– Adjudicated Claim Information

– Claim Voids and Replacements

– Most Common Denials

– Helpful Tools


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Objectives

At the end of this session, providers will understand:

– The origin of the Medicaid waiver program

– Requirements necessary for a member to qualify for waiver services

– How spend-down impacts claim processing

– How to verify member eligibility

– How to submit and adjust claims

DefineMedicaid Waivers


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Definition of a Medicaid Waiver

– In 1981, the federal government created Title XIX Home and Community-Based Services (HCBS) Program

– This act, referred to as the waiver program, created exceptions to, or “waived,” traditional Medicaid requirements

– A waiver is what the State government requested from the Centers for Medicare & Medicaid Services (CMS) to obtain additional funding through the Medicaid program• It allows for the provision and payment of HCBS that are not provided through the Medicaid State plan

– Medicaid waiver programs are funded with both State and federal dollars

– All Indiana waiver programs have been initiated by the Indiana General Assembly and approved by CMS


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What Is the HCBS Waiver Program?

– Traditionally, Medicaid paid for institutional-based services only; however, the HCBS waiver program allowed services to be “waived” from Traditional Medicaid payment methodology

– The Medicaid HCBS waivers fund supportive services to individuals in their own homes or in community settings, rather than in a long-term care facility setting

– The Medicaid HCBS waivers fund services to individuals who:• Meet the level of care specific to a waiver

• Meet the financial limitations established by the waiver


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What Is the HCBS Waiver Program?

– In addition to waiver services, waiver members receive all Medicaid services under the State Plan (Traditional Medicaid), for which they are eligible

– The State administers five HCBS waivers and two grants under three distinct categories:• Nursing Facility Level of Care Waivers (includes two waivers/one grant)

• Intermediate care facility for the mentally retarded (ICF/MR) Level of Care Waivers (includes three waivers)

• Psychiatric Residential Treatment Facilities Level of Care Grant


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HCBS Waivers

Nursing Facility Level of Care Waivers and Grant

Administered by the Division of Aging (DA)

– Aged and Disabled Waiver (AD)

– Traumatic Brain Injury Waiver (TBI)

– Money Follows the Person (MFP) Demonstration Grant

ICF/MR Level of Care Waivers

Administered by the Division of Disability and Rehabilitative Services (DDRS)

– Developmental Disabilities Waiver (DD)

– Autism Waiver (AU)

– Support Services Waiver (SS)


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HCBS Waivers

Psychiatric Residential Treatment Facilities Level of Care Grant

Administered by the Division of Mental Health and Addiction (DMHA)

– Community Alternatives to Psychiatric Residential Treatment Facilities Demonstration Grant (CA-PRTF)


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Community Alternatives to Psychiatric Residential Treatment Facilities

– Demonstration project through CMS

– Goal is to demonstrate that cost-effective, intensive community-based services can serve as alternative to treatment in a psychiatric residential treatment facility (PRTF) or assist in a child/youth’s transition back to the community from a PRTF

– More than 41 million federal dollars for a five-year duration beginning in 2007

– Eight services are offered: Wraparound Facilitation, Wraparound Technician, Respite Care, Non-Medical Transportation, Habilitation, Clinical, Flex Funds, Consultative Clinical and Therapeutic Services, and Training and Support for Unpaid Caregivers

– More information about services offered and rates: in.gov/fssa/dmha/6643.htm

http://www.in.gov/fssa/dmha/6643.htm


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Community Alternatives to Psychiatric Residential Treatment Facilities

– 56 Indiana counties serve as access sites for grant services

– DMHA is seeking more counties to serve as access sites to allow for statewide access

– Additional counties may participate as an access site if:• The county can document that it meets the requirements; or,

• A DMHA-approved access site in another county agrees to provide services on behalf of the interested county


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Money Follows the Person (MFP)

– Demonstration program through CMS

– Helps interested individuals transition out of a nursing facility and into a community-based setting

– ADVANTAGE Health Solutions case managers help facilitate transition

– Participants may receive waiver services plus additional program services:• Additional transportation

• Personal Emergency Response System

– After 365 days, participants transfer seamlessly to one of the waivers


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Indiana FSSA Waiver Divisions

The following divisions support the administration of the HCBS waivers and grants:

–Developmentally Disabled, Support Services, and Autism Waivers:

Division of Disability and Rehabilitative Services402 W. Washington St., Room W453Indianapolis, IN 46207

–Aged and Disabled and Traumatic Brain Injury Waivers and Money Follows the Person Demonstration Grant:

Division of Aging402 W. Washington St., Room W454Indianapolis, IN 46207

–Community Alternatives to PRTF Demonstration GrantDivision of Mental Health and Addiction

402 W. Washington St., Room W353Indianapolis, IN 46204

DescribeMember Eligibility


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Where Does Eligibility Begin?

Medicaid enrollment process starts with the Division of Family Resources (DFR):

–Enters member application into the eligibility tracking system known as the Indiana Client Eligibility System (ICES)

–Determines member eligibility status

–Makes spend-down determinations if necessary

–Maintains member information and eligibility files

Division of Family Resources


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Where Does Eligibility Begin?

– If an individual is found to meet waiver Level of Care requirements but is not Medicaid-eligible, the individual may become Medicaid-eligible under special waiver eligibility rules

Exception to the rule


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Waiver Program Eligibility

Members must qualify for waiver program eligibility

– Individuals who meet waiver Level of Care status and are Medicaid eligible may be approved to receive waiver services

– A limited number of slots are approved by the CMS for each waiver

– A Medicaid-eligible individual cannot receive waiver services until:

• A funded slot is available

• A waiver Level of Care is established for the member

• A cost-comparison budget is approved (demonstrates cost-effectiveness of waiver services when compared to institutional costs)


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Waiver Program Eligibility

Once eligibility requirements are met:

– A case manager, along with the client and/or client’s representative, as well as other service providers, develop a Plan of Care (POC), and/or an Individualized Support Plan, which is reviewed by the State

– The Notice of Action (NOA) lists the approved services the client may receive, along with the approved date span, units, and charge per unit

– Information from the NOA is sent to HP for placement on the member’s Prior Authorization (PA) record for appropriate claims payment

– Claims pay only if PA dollars, units, and services are available for the dates of service submitted on the claim

– An approved Notice of Action is not a guarantee of claims payment– Providers must verify member eligibility to ensure Medicaid coverage and

Waiver Level of Care


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Member Eligibility

– Receives member data from Indiana Client Eligibility System (ICES)

– Updates IndianaAIM within 72 hours

– Provides and supports the Eligibility Verification System (EVS)

– Makes EVS available 24 hours a day, seven days a week

HP role


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Member Eligibility

Even for members enrolled in a HCBS Waiver program, it is the provider’s responsibility to verify eligibility prior to providing service(s)

Three EVS options are available:

–Automated Voice Response (AVR)

–Omni swipe card terminal device

–Web interChange

The necessity of verifying members' eligibility


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Automated Voice Response

AVR provides the following:

– Member eligibility verification

– Benefit limits

– Prior authorization

– Claim status

– Check/RA Inquiry

Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770

EVS using the telephone


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Omni

– Is cost effective for high-volume providers

– Uses plastic Hoosier Health card

– Allows manual entry

– Prints two-ply forms

– Requires upgrade for benefit limit information

See Chapter 3 of the IHCP Provider Manual for more information, available at indianamedicaid.com

EVS card-reading device

http://www.indianamedicaid.com/


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Web interChange

The following is available throughWeb interChange:

–Member information available by Member ID, SSN, Medicare Number, or Name and DOB

–Spend-down information

–Detailed third-party liability (TPL) information

–Online TPL update requests

–Web interChange is accessible via provider.indianamedicaid.com

EVS using the Internet

http://provider.indianamedicaid.com/

LearnWaiver Billing Information


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Waiver Billing Guidelines

When billing for HCBS Waiver services, it is important to have the Notice of Action available to bill properly

–Notice of Action• Lists the approved service providers

• Lists the approved service codes and modifiers

• Gives the approved number of units and dollar amounts

Note: Units on the NOA may be in time increments

–Refer to the HCBS Waiver Provider Manual for information regarding:

• Service definitions

• Allowable services

• Service standards

• Documentation standards


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Authorized Services

You may only bill for authorized services. For services to be authorized they must:

–Meet the needs of the member

–Be addressed in the member’s Plan of Care (POC) and/or Individualized Support Plan (ISP)

–Be provided in accordance with the definition and parameters of the service, as established by the waiver


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Claim Form and National Provider Identifier– Waiver providers should submit their claims electronically via the

837P transaction or on Web interChange

– The CMS-1500 claim form is used when submitting paper claims

– Waiver providers are considered atypical and do not report a National Provider Identifier (NPI) on their claims

– Waiver providers submit claims using their Legacy Provider Identifier (LPI) with the alpha location suffix

– Waiver providers do not report or use a taxonomy code


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Spend-down

– Spend-down is assigned by the Division of Family Resources at the time of the eligibility determination

– The member is aware of the spend-down amount and responsible for fulfilling that obligation

– HP credits the member’s spend-down based on the usual and customary charge billed on the claim

– Spend-down is credited on claims based on the order they are processed

– ARC 178 appears on the Remittance Advice when spend-down is credited on claims

– Providers may bill the member for the amount listed beside ARC 178

– Member is responsible to pay upon receipt of the Spend-down Summary Notice


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Web interChangeProfessional Claims – Medical


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Claim Completion


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Claim Completion


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– Under the Professional Claims heading, click the Medical link

– Your billing Legacy Provider Identifier (LPI) should be indicated in the Legacy Provider ID field. Type the letter that corresponds to your location code (for example, 200400000A) immediately following the LPI

– Complete the following fields: Member ID, Last Name, First Name, Patient Account #, Rendering LPI, Place of Service, and Diagnosis Code (V709)

Web interChange Billing


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Entering detail information

– Complete the following fields for the first claim detail in the Detail Information section: From DOS, To DOS, Procedure Code, Modifiers, Related Diagnosis (if needed), Place of Service, Units, and Charges.

– Click Save Detail. A summary of the detail information displays in the box at the bottom of the screen to confirm that the information saved.

– To add additional detail lines on the same claim, click Add Detail. Repeat the step above step until all details are added.

Submitting the claim

– Click Submit Claim on the bottom of the screen.

– When the confirmation pop-up window appears with the claim’s internal control number (ICN), confirm the information, and click OK to complete the process and send the claim to HP.

Web interChange Billing


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CMS-1500 Claim Form


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– Field 1: INSURANCE CARRIER SELECTION – Enter X for Traditional Medicaid. Required.

– Field1a: INSURED’S I.D. NUMBER (FOR PROGRAM IN ITEM 1) – Enter the IHCP member identification number (RID). Must be 12 digits. Required.

– Field 2: PATIENT’S NAME (Last Name, First Name, Middle Initial) – Provide the member’s last name, first name, and middle initial obtained from the Automated Voice Response (AVR) system, electronic claim submission (ECS), Omni, or Web interChange verification. Required.

– Field 17b: NPI – Enter the qualifier ‘1D’ and the LPI of the referring provider (case manager). Required.

– 21.1: DIAGNOSIS OR NATURE OF ILLNESS OR INJURY – V709 will always be used when billing Waiver services. Required.

– 24A: DATE OF SERVICE – Provide the FROM and TO dates in MMDDYY format. Required.

CMS-1500 Billing Guidelines


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– 24B: PLACE OF SERVICE – Use the Place of service code for the facility where services were rendered. Required.

– 24D: PROCEDURES, SERVICES, OR SUPPLIES – Use the Billing service code in conjunction with appropriate modifiers. Required.

– 24E: DIAGNOSIS CODE – Enter number 1–4 corresponding to the applicable diagnosis codes in field 21. A minimum of one, and a maximum of four, diagnosis code references can be entered on each line. Required.

– 24F: $ CHARGES – Enter the total amount charged for the procedure performed, based on the number of units indicated in field 24G. Required.

– 24G: DAYS OR UNITS – Provide the number of units being claimed for the procedure code. Six digits are allowed, and 9999.99 units is the maximum that can be submitted. The procedure code may be submitted in partial units, if applicable. Required



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– 24J Top Half – Shaded Area: RENDERING PROVIDER ID – Enter the 1D qualifier in 24I for the Rendering Provider ID. LPI – The entire nine-digit LPI must be used. If billing for case management, the case manager’s number must be entered here. Required.

– 28: TOTAL CHARGE – Enter the total of all service line charges in column 24F. Required.

– 30: BALANCE DUE – TOTAL CHARGE Required.

– 31: SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS – An authorized person, someone designated by the agency or organization, must sign and date the claim Required..

DATE – Enter the date the claim was filed.

– 33: BILLING PROVIDER INFO & PH # – Enter the billing provider office location name, address, and the ZIP Code+4. Required.

– 33b: BILLING PROVIDER QUALIFIER AND ID NUMBER; If the billing provider is an atypical provider, enter the qualifier 1D and the LPI. Required.



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Paper Claim Filing

– Use the approved version of the CMS-1500 claim form

– Verify that the claim form is signed, or complete the Attestation for Signature on File

– Send paper claims to:

HP Waiver Program ClaimsP.O. Box 7269Indianapolis, IN 46207-7269

– Review the Remittance Advice (RA) closely

Helpful hints


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Remittance Advice

– Remittance Advices (RAs) provide information about claims processing and financial activity related to reimbursement

• RAs contain internal control numbers (ICNs) with detail-level information

• RAs give detail status (paid or denied)

• RAs give payment amount

See the IHCP Provider Manual Chapter 12 for more details

- Remittance Advices are available on Web interChange• Under the Check/RA Inquiry tab

Statement with claims processing information


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Claim Adjustments

– “Replacement” is a HIPAA-approved term used to describe the correction of a claim that has already been submitted

– Replacements can be performed on paid, suspended, and denied claims

– Denied details can be replaced or billed as a new claim

– To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year from the date of service

– “Void” is the term used to describe the deletion of an entire claim

– Voids can be performed on paid claims only

– Voids and replacements can be performed to correct incorrect or partial payment, including zero dollar amount

Note: Paper replacements can only be processed on paid claims

Voids and replacements

ResolveMost Common Denials


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Most Common Denials

– Cause• The claim is an exact duplicate of a previously paid claim

– Resolution• No action required, as the claim has already been paid

Edit 5001 – Exact Duplicate


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Most Common Denials

– Cause• Provider has billed a procedure code that is invalid for the waiver program

– Resolution• Verify the correct procedure code has been billed

• Verify the procedure code billed is present on the Notice of Action

• Correct the procedure code and rebill your claim

Edit 4216 – Procedure Code not Eligible for Recipient Waiver Program


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Most Common Denials

– Cause• Waiver provider has billed for a recipient who does not have a waiver Level of

Care for the date of service

– Resolution• Contact the waiver case manager to verify the LOC information is accurate

• Verify the correct date of service has been billed

• If code billed is incorrect, correct the code and rebill

Edit 2013 – Recipient Ineligible for Level of Care


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Most Common Denials

– Cause• The date of service billed is not on the prior authorization file

– Resolution• Verify the correct date of service has been billed

• Verify the date of service billed is on the Notice of Action

• Verify the procedure code billed is present on the Notice of Action

Edit 3001 – Date of Service Not on PA Database

Find HelpResources Available


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Helpful ToolsAvenues of resolution

– IHCP Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD, or paper)

– HCBS Waiver Provider Manual

– EVS Technical Support• HP Electronic Solutions Help Desk at 1-877-877-5182

– Customer Assistance• Local (317) 655-3240• All others 1-800-577-1278

– Written Correspondence• HP Provider Written CorrespondenceP. O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant

http://www.indianamedicaid.com/


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Helpful ToolsAvenues of resolution

– Division of Disability and Rehabilitative Services402 W. Washington St., Room W453Indianapolis, IN 46207

– Division of Aging402 W. Washington St., Room W454Indianapolis, IN 46207

– Division of Mental Health and Addiction402 W. Washington St., Room W353Indianapolis, IN 46204

HP Provider Relations October 2011 HCBS Waiver Program Guidelines and Billing.

Documents

Transcript of HP Provider Relations October 2011 HCBS Waiver Program Guidelines and Billing.