IHCP Updates

HP Provider RelationsFebruary 2011

IHCP Updates

IHCP Updates February 20112

Agenda– Objectives

– Transition and Testing for American National Standards Institute (ANSI) Version 5010

– National Correct Coding Initiative

– Dental Cap

– Diabetic Supply List

– Therapy Service Changes

– Vision Service Changes

– Long Term Care Changes

– Changes to Reimbursement Rates

– Presumptive Eligibility/Notification of Pregnancy

– Prior Authorization for Inpatient Hospitals

– Universal Prior Authorization Form

– Software Download for Omni Users

– Customer Service Inquiries

– Helpful Tools

– Questions


Objectives

– Know about the transition to the Health Insurance Portability and Accountability Act (HIPAA) version 5010

– Understand NCCI and the impact on claim processing

– Know about the changes/updates related to your provider type

– Understand the Prior Authorization process for inpatient admissions

– Become aware of the universal prior authorization form

– Know about the need to update the Omni system

ExplainHIPAA 5010


HIPAA 5010– The mandatory compliance date for ANSI version 5010 and the

National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012

– IHCP 5010 Companion Guides and Upcoming Changes document are available at www.provider.indianamedicaid.com• Upcoming Changes document contains only segments that are updated, added,

or deleted

http://www.provider.indianamedicaid.com/


HIPAA 5010– If submitting claims to the IHCP, you need to be aware of the

upgrades to prevent delay in payment

– Transactions affected by this upgrade:• Institutional claims (837I)• Dental claims (837D)• Medical claims (837P)• Pharmacy claims (NCPDP)• Eligibility verifications (270/271)• Claim status inquiry (276/277)• Electronic Remittance Advices (835)• Prior authorizations (278)• Managed Care enrollment (834)• Capitation payments (820)


Testing Information

– All trading partners currently approved to submit 4010 and NCPDP 5.1 versions are required to test and be approved for 5010 and D.0 transaction compliance • Scheduled testing started in January for software vendors, clearinghouses, and

billing services

– Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test

– Providers that submit data via Web interChange do not need to test

–Each trading partner is required to submit a new Trading Partner Agreement


What You Need To Do– If you bill IHCP directly

• Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions

– If you are using a billing service or clearinghouse• Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0

– Questions should be directed to [email protected] OR

– Call the EDI Solutions Service Desk• 1-877-877-5182 or (317) 488-5160

– Watch for additional information in bulletins, banner pages, and newsletters at www.indianamedicaid.com

mailto:[email protected]

http://www.indianamedicaid.com/

DefineNational Correct Coding Initiative


National Correct Coding Initiative

– In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment

– NCCI has been in place for many years and most providers are familiar with the editing methodologies with Medicare

– Also included in NCCI editing are:• Claims with Third Party Liability (TPL) amounts• Claims denied by the primary insurance

What is it?


National Correct Coding InitiativeInitial editing encompasses three basic coding concepts

• This pair of edits represent two codes that normally should not be reported together.

• Column One indicates the correct code, and Column Two indicates the incorrect or inappropriate code(s) in relation to the Column One code.

• Identifies procedures that cannot be reasonably performed on the same day because they are mutually exclusive.

• These procedures cannot be performed at the same anatomic site or same patient encounter.

• The maximum units of services that a provider would report under most circumstances for a single member on a single date of service.

• If the provider bills for more units than the amount of units established by MUE for that procedure code, that detail line will be denied when the claim is processed for NCCI editing.

Column One Column Two

Mutually Exclusive Procedures (ME)

Medically Unlikely Edits (MUE)


National Correct Coding Initiative

– NCCI will affect providers submitting the following:• Institutional outpatient claims

•Professional claims

– Professional claim implementation began January 27, 2011

– Institutional claim implementation begins April 1, 2011

– Watch for more information in your bulletins, banner pages, and newsletters at www.indianamedicaid.com

– The NCCI policy manual is available at http://www.cms.gov/NationalCorrectCodInitEd

Who will be affected?


http://www.cms.gov/NationalCorrectCodInitEd

ExplainDental Cap


Dental Cap Limit

Effective with dates of service January 1, 2011

–$1,000 Cap• Calendar year cap• Applies to members 21 and above

Previous cap was for members 19 and over• All Indiana Health Coverage Programs (IHCP), including Traditional

Medicaid, Hoosier Healthwise, and Care Select • Web interChange displays amount of cap met • Exceptions

Hospital place of service 21 or 22• Any service provided in a hospital setting is exempt from the cap

Additional information may be found in BT201059

DescribeDiabetic Supply List


Preferred Diabetic Supply List (PDSL)

Changes effective for dates of service January 1, 2011, and after

– Provider Types• Durable Medical Equipment (DME)• Pharmacy

– Preferred Vendors• Abbott Diabetes Care• Roche Diagnostics



Changes effective for dates of service January 1, 2011, and after

– Blood Glucose Monitors• Freestyle Life System• Freestyle Freedom Lite System• Precision Xtra Meter• Accu-chek Aviva Care

– Diabetic Test Strips• Freestyle Lite Test Strips• Precision Xtra Test Strips• Accu-chek Aviva Care Diabetic Test Strips

Supplies list


Preferred Diabetic Supply List (PDSL)– Members Affected• All Indiana Medicaid members• Healthy Indiana Plan members

– Members currently utilizing a blood glucose monitor were required to convert to the preferred products • There was no additional cost to the member or provider

– Members continue to have no copayment for blood glucose monitors and diabetic test strips, regardless of their inclusion on the PDSL

– Members subject to spend-down are still responsible for any spend-down liability after the claim adjudicates

– Members were notified by mail of the changes and directions on how to obtain a new monitor at no cost

• Providers should continue to provide training to members in regard to the preferred blood glucose monitors and/or refer the members to the manufacturer of the product



Claims for dates of service on or after January 1, 2011

– Professional Claims Affected• CMS-1500 Paper Claims• Web interChange• Batch (837P Transactions) Claims

– Claim Submission• Claims must be submitted to the fee-for-service (FFS) medical benefit

Includes all Indiana Medicaid Members Includes all Healthy Indiana Plan members

Billing guidelines



National Drug Code (NDC) Requirement– N4 qualifier required– Corresponding 11-digit NDC required

• Utilize the 5-4-2 format

– Unit of measure• UN

– Required on all claims• Medicare Crossover claims• Third Party Liability (TPL) claims

Billing guidelines



– Procedure Codes Utilized• E0607 – Home blood glucose monitor• A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips

– Modifiers• NU and RR modifiers are not used for E0607, E0607 U1, A4523 and A4523 U1 for supplies

that are on the PDSL Effective with dates of service January 1, 2011, and after Exception – Medicare crossover claims require the appropriate modifier Exception – TPL claims for non-preferred PDSL require the U1

– Prior Authorization• Claims for blood glucose monitors and test strips not included in the PDSL will require prior

authorization• Diabetic test strip quantities exceeding 200 strips per month require prior authorization

Additional information can be found in BT201055

Billing guidelines

DefineTherapy Service Limitations


Therapy Service LimitationsEffective with dates of service January 1, 2011, new limits for physical, occupational, and speech therapy were imposed

–Twenty-five visit limit• Per rolling 12-month period

• Applies to members 21 and older

• Prior authorization (PA) will no longer be required for physical therapy, occupational therapy, and speech therapy services for members age 21 or older−PA is still required for members under 21

• Limit is for each type of therapyA “visit” is defined by the type of therapy and date of service. For

example, a member receives physical therapy from a provider during a one-hour visit. That member receives physical therapy services defined with procedure codes 97116, 97140, 97530, and 97532 during the visit. This is counted as one “visit” toward the member’s limitation.


DescribeVision Services


Vision ServicesEffective with dates of service January 1, 2011, new limits for covered eyeglass benefits

–One pair per year for recipients under 21• Previously applied to members under 19

–One pair every five years for recipients 21 and over

• Previously applied to members over 19• Previously one pair every two years

–Affects all IHCP Programs• Traditional Medicaid• Hoosier Healthwise• Care Select


Note: HIP does not cover vision services

ExplainLong Term Care


Long Term Care – Facility Leave Days

Effective February 1, 2011, bed hold days are no longer reimbursed

–Revenue Codes• 180 – nonpaid• 183 – therapeutic leave• 185 – hospital leave

–Impacts all Indiana Health Coverage Programs Members

• Members in nursing facilities were notified

–Providers should inform members of their bed hold policy

• Members may be charged for the bed hold if they choose the service


ExplainReimbursement Rates


Five Percent Rate ReductionEffective with dates of service January 1, 2011, and after– Attendant Care

• Based on billing provider type 32 – waiver


– Chiropractors• Based on rendering provider specialty 150• Will occur at the claim level detail

Reduction will apply prior to subtracting any third-party liability or spend-down amount


– Podiatrist• Based on rendering provider specialty 140• Will occur at the claim level detail

Reduction will apply prior to subtracting any third-party liability or spend-down amounts



TransportationNew rates effective with dates of service January 1, 2011, and after

–Five percent reduction• Ambulance transportation providers

–Ten percent reduction• Non-ambulance transportation providers

Reduction will apply prior to subtracting any third-party liability or spend-down amounts

Transportation providers are able to access the reduced rates on the IHCP fee schedule at www.indianamedicaid.com



ExplainPresumptive Eligibility/Notification of Pregnancy


Presumptive Eligibility (PE)

– PE Application• Review application for accuracy prior to

submission Name Date of birth Address

• Contact HP provider field consultant for corrections on the application to the demographic information listed above

• One approved application per pregnancy Do not override the warning except for:

– Pre-term delivery– Abortion– Miscarriage


Presumptive Eligibility (PE)

– Contacting the enrollment broker• As of January 1, 2011

Members choose a managed care entity (MCE)– Previously, members chose a primary care physician (PMP)

MCE must be chosen the same day application is submitted MCE will add the PMP when assigned Eligibility may not reflect a PMP immediately Claims should be submitted to the MCE listed on the eligibility verification


Notification of Pregnancy (NOP)

– Submitting NOP information• Information cannot be changed once submitted• Review information for accuracy prior to submitting

– Duplicate NOPs (same woman, same pregnancy) do not qualify for reimbursement

– Providers will receive an on-screen message if the NOP appears to be a duplicate

ExplainPrior Authorization


Prior Authorization (PA)

Effective with admit date of service on January 1, 2011, and after

– Prior authorization is required for all non-emergent inpatient hospital admissions• Elective or planned inpatient admissions• Applies to members of all ages with Traditional Medicaid and Care Select• Request PA via the telephone

At least two days in advance– Outside of normal business hours, weekends and holidays – within 48 hours

of admission Contact ADVANTAGE Health Solutions for Care Select members assigned to

ADVANTAGE at 1-800-784-3981 Contact MDwise for MDwise Care Select members at 1-866-440-2449 Contact ADVANTAGE Health Solutions for fee-for-service members at 1-800-

269-5720

Elective inpatient hospital admissions



– Excluded from PA requirement• Emergent admissions• Routine Vaginal and C-Section deliveries• Newborn stays• Medicare/Medicaid dual eligible member

admissions• Observation


Elective inpatient hospital admissions

DefinePrior Authorization



– Universal form required effective January 1, 2011

– All providers• All IHCP Programs

Traditional Hoosier Healthwise Care Select Healthy Indiana Plan (HIP)

– PA form and instructions are available at www.indianamedicaid.com under the Forms link

Universal prior authorization form




– Exception• Dental

Dental PA form available on the IHCP website

• Pharmacy

Pharmacy PA form available on the IHCP website

• Behavioral Health

Traditional Medicaid and Care Select DO use the Universal PA Form

– Indicate "Mental Health" or "MRO" in the upper left hand corner

Hoosier Healthwise-Risk Based Managed Care and Health Indiana Plan (HIP)

– Use the form authorized by the individual MCE


Universal prior authorization form


Prior Authorization (PA)Universal prior authorization form

DefineOmni Download


Omni Download Required

– Required to obtain correct primary care physician (PMP) information when checking eligibility• Omni will show “No PMP assigned" after

upgrade

– Instructions for download • Refer to BT200711, Table 1.1• IHCP Provider Manual Chapter 3, Table 3.7

– For assistance contact the Omni help desk• (317) 488-5051• 1-800-284-3548

Additional information may be found in BR201049

DefineCustomer Service Inquiries


Customer Service Inquiries

– Claim Status• Verify claim status on the Web interChange

Claim inquiry

– Procedure Code Coverage• Verify procedure code coverage, program

coverage, and prior authorization requirements on the fee schedule

– Spend-down Information• IHCP Provider Manual Chapter 2, Section 4 and

Chapter 5, Section 5• Provider Education – Archived Workshop

PresentationsSpend-down

Find HelpResources Available


Helpful Tools

– IHCP Web site at www.indianamedicaid.com

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

– IHCP Fee Schedule

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence

• P.O. Box 7263Indianapolis, IN 46207-7263

– Provider field consultant • http://www.indianamedicaid.com/ihcp/ProviderServices/

pr_list_frameset.htm


http://www.indianamedicaid.com/ihcp/ProviderServices/pr_list_frameset.htm

http://www.indianamedicaid.com/ihcp/ProviderServices/pr_list_frameset.htm

IHCP Updates

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