MLTC Provider Billing Manual - Independence Care … Provider Billing Manual ... 1.1 Welcome to...
Transcript of MLTC Provider Billing Manual - Independence Care … Provider Billing Manual ... 1.1 Welcome to...
MLTC Provider Billing Manual
For Independence Care System’s Medicaid Managed Long-term Care (MLTC) Plan
April 2015
TABLE OF CONTENTS
Section 1: Introduction 1.1 Welcome to Independence Care System
1.2 How To Use This Manual
1.3 Our Care System
Section 2: ICS Operating Procedure 2.1 Coordination of Benefits
2.2 Referrals for Services
Section 3: Claims Processing 3.1 Paper Claims Submissions
3.2 Electronic Claims Submissions & Payer ID
3.3 Claim Appeals
3.4 Payments
3.5 Helpful Hints for Quick Claims Processing
3.6 Common Causes of Delayed Payments
Section 4: Specialty Services Authorization and Billing Guidelines 4.1 Adult Day Health Care
4.2 Audiology
4.3 Dental
4.4 Durable Medical Equipment
4.5 Home Care Aide Services
4.6 Home Delivery of Meals
4.7 Medical Supplies
4.8 Nursing Home Care
4.9 Nutrition Services
4.10 Optometry Services
4.11 Personal Emergency Response System (PERS)
4.12 Podiatry
4.13 Rehabilitation Services
4.14 Respiratory Services
4.15 Skilled Home Health Care Services (RN, LPN, MSW)
4.16 Social Day Care
4.17 Transportation
Section 5: Standard Form Samples 5.1 UB-04 Sample Claim Form
5.2 CMS 1500 Sample Claim Form 5.3 Dental Sample Claim Form
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Section 1: Introduction
1.1 Welcome to Independence Care System
Welcome to Independence Care System! We are happy to have you as part of our Provider
Network.
Independence Care System is a nonprofit organization committed to assisting senior adults and
people with disabilities to live independently in their communities. ICS operates a Medicaid
managed long-term care plan (MLTC) called ICS Community Care and beginning in 2015, a
fully capitated Medicaid and Medicare Plan called Community Care PLUS FIDA-MMP. Our role
in our members’ lives is to coordinate a comprehensive range of health and long-term care
services.
ICS Community Care serves Medicaid-eligible individuals over 18 years of age with physical
disabilities or chronic illness who reside in the Bronx, Brooklyn, Manhattan and Queens. ICS
Community Care PLUS serves adults over 21 years of age who reside in the Bronx, Brooklyn,
Manhattan and Queens.
This Manual is for Community Care/MLTC providers. For a copy of the Provider Manual for
Community Care PLUS FIDA-MMP providers, email [email protected], call Provider
Relations at 646.653.6188, or go to our website at www.icsny.org. You can learn more about ICS
at our website.
1.2 How To Use This Manual
This Manual will serve as your guide to working with ICS. It contains information to help you
understand how the ICS referral for services and billing procedures work. The Manual is
organized in sections that reflect our service categories. We hope this guide is helpful to you and
we welcome feedback on how to improve the guide or our working relationship.
We encourage you to review this material carefully and refer to it when you have a question.
You may also email any questions to our Provider Relations Department at [email protected].
1.3 Our Care System
At Independence Care System, we pride ourselves on member-centered care. Our care system
demonstrates our passion and commitment to our members.
Responsive: What’s important to our members and our member’s family is important to us.
We work with our members—or with our member’s family—to assess their needs for home care,
health care and social services, and to develop their personalized care plan. We ensure that the
plan reflects what they see as their needs, as well as the services that are most crucial to their
health, safety and well-being.
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Coordinated: We work with members to get the health care and social services they need.
The ICS team coordinates all of the home care, personal assistance, housekeeping, health care
and social services members need, working with the member’s primary care doctor, physician
specialists, home care agency, and a wide array of community-based providers.
Expert: A highly skilled, dedicated, diverse staff, advocating for the member and with the
member to be as independent as they can be.
Members work with a team of ICS professionals, backed by the resources of our full time staff,
including: Social Workers, Registered Nurses, Multiple Sclerosis-certified and wound-certified
nurses, Medicare and Medicaid eligibility specialists, rehabilitation therapists, wheelchair repair
technicians, transportation managers, and organizers of artistic, educational and social programs
especially for ICS members.
Empowering: Giving the member the knowledge and skills they need to make informed decisions.
Members are at the center of all of the decision-making about their care; they have the final say.
Respectful: A culture of listening and understanding, where members feel they belong.
ICS is at its core a community, made up of our members, their families and caregivers, providers,
and our staff. In coordinating the services our members need, we are committed to nurturing that
sense of community, to ensuring that everyone is treated with respect and that their voices are
heard.
Flexible: When the member’s life changes, so do our services.
The services our members need when they join ICS may not be the same services they need six
weeks, six months, or six years later. Maybe they fell, were hospitalized, landed in a nursing
home, and were terrified that they would never get out. At times like that, ICS is there, making
the changes they need, shepherding them through the transitions they face, getting them back
home.
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Section 2: ICS Operating Procedures
2.1 Coordination of Benefits
As a Medicaid managed long-term care plan, ICS is the payor of last resort for covered
authorized services. If a service that has been ordered is provided to a member that has other
coverage for that benefit from Medicare and/or other Third Party Health Insurance (TPHI), an
Explanation of Benefit (EOB) or Explanation of Payment (EOP) from that insurer must be
submitted to ICS in order for a provider to receive payments from ICS. Medicare deductibles are
paid in full by ICS. If another insurer has made a payment for service, we will pay co-pays for
covered services according to the rules below:
For most services ICS will pay the difference between the payments from other insurers
and the ICS allowed charge. If payments from other payers equal or exceed the ICS
allowed charge, no payment will be made.
For medical supplies, nursing homes, respirators (i.e., ventilators), eyeglasses and on-
site rehabilitation services, ICS will pay the amount of the Medicare co-pay.
For certified home health agency (CHHA) services there is no co-pay.
The provider is required to maintain, and make available to ICS upon request, records of
coordination of benefits proceeds collected by the provider and amounts paid by third
parties directly to members.
By law, providers are not allowed to charge ICS members for services covered by ICS Medicaid
or Medicare.
2.2 Referrals for Services
All covered services require a written authorization from an ICS care manager, except for urgent,
non-emergency services, which may be provided upon receipt of a verbal referral from the care
manager. Referrals may be for limited duration or may be standing referrals for ongoing care
from a specialist provider. If services are provided without an authorization, payment may be
denied. No member will be referred for services unless he/she is eligible for ICS covered
services. The referral will serve as validation of membership, as well as authorization to provide
services.
The care manager is either a Nurse or a Social Worker who is primarily responsible for
coordinating the health and long-term care services of a member. Each care manager works as
part of a larger unit that includes member services coordinators who provide support to both the
Members and the Care Managers.
Authorization is not a guarantee of payment.
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Providers who believe that an individual member may need additional or different non-covered
or specialty services from what they are currently receiving should discuss their concerns with
the care management staff. The staff is responsible for assisting members to obtain needed
services even if those services are not covered by ICS.
Providers who are unable to accept a referral must notify the ICS care manager within 48 hours
of receiving the referral, or within 24 hours for skilled nursing home care services.
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Section 3: Claims Processing
Effective October 1, 2013 Independence Care System has contracted with Productive
Processing Inc. (PPI) to provide claims processing and administrative services. When
submitting claims to PPI, you may submit paper or electronic claims. Submitting electronically
will allow us to process your claims faster and more efficiently.
3.1 Paper Claims Submissions
Mail to:
Independence Care System
c/o Productive Processing Inc.
319 Yard Drive
Verona, WI 53593-8434.
3.2 Electronic Claims Submissions & Payer ID
The ICS Payer ID is: 13396. ICS works with two clearinghouses:
MD Online (preferred)
Phone: 1-888-499-5465 (Option 1)
www.mdon-line.com
Emdeon
www.emdeon.com
Providers can also call the PPI toll free customer service number at: 877.585.1131 for assistance
setting up the submission of EDI claims.
3.3 Claim Appeals
Mail to:
Independence Care System
Attention: Provider Claim Appeals
257 Park Avenue South, 2nd Floor
New York, NY 10010
Appeals must be filed within 30 days of the date of the denial letter.
Determination will be completed within 45 days of the appeal submission.
Instructions for ICS Provider Billing – Page 3
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3.4 Payments
Claims and Invoices will be paid within 30 days of receipt for EDI claims and 45 days of receipt
for paper claims, if they meet the following criteria:
Received within 120 days of the date of service, and properly and accurately
completed;
Matches the ICS authorization for services and has the appropriate modifiers; and
Requests the appropriate payment.
All claims received more than 120 days after the date of service will be automatically denied for
untimely filing unless accompanied by an EOB or EOP from another payor.
If ICS requires additional information or documentation, ICS will pay any undisputed portion of
the claim within 45 days and notify the provider of the need for additional information within 30
days of receiving the claim.
Payment rates are based on negotiated rates reflected in the specific ICS/provider contract.
3.5 Helpful Hints for Quick Claims Processing
Providers should bill electronically, if possible.
Claims must include Member Medicaid ID / ICS Member ID.
Providers must include the appropriate CPT/HCPCS codes and modifier on all
submitted claims.
Providers must use the organization name (not individual provider) with the
corresponding Tax ID in Box 33 on the HCFA form and Box 1 on the UB-04 form.
ICS will only pay claims where the Tax ID on the form matches the contracted tax
ID.
3.6 Common Causes of Delayed Payments
HCPCS code and modifier not matching exactly with the authorization
Member Medicaid ID and/or ICS Member ID not included on the form
Untimely submission of claims (after 120 days of DOS)
Individual provider and tax ID used, as opposed to name and tax ID of contracted
organization
In addition, please note that EDI claims are generally processed faster than paper claims.
Instructions for ICS Provider Billing – Page 4
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Section 4: Specialty Services Authorization and Billing Guidelines
4.1 Adult Day Health Care
4.1.1 What Is Covered?
Adult day health care (ADHC) provides skilled services such as nursing, physical, speech, and
occupational therapies in a day program setting offered by a residential health care facility or
approved extension site. Other services available in ADHC are: nutritional counseling,
socialization activities, dentistry, podiatry, and administration of medications. Transportation to
and from the facility may be included in the daily rate.
4.1.2 Exclusions
ADHC should not be used for socialization reasons only (please see New York State
Office of the Aging Social Adult Day Care Regulations [9NYCRR 6654.20 Social
Adult Day Care Programs]).
4.1.3 Approval Needed
MD order required
ICS authorization required
4.1.4 Billing
Type of claim form: UB-04 (See page 26)
4.1.5 Fee schedule
Please refer to your ICS contract.
4.2 Audiology
4.2.1 What Is Covered?
Hearing exam
Hearing aid evaluation
Selecting, fitting, dispensing of hearing aids
Hearing aid repair
Replacement of accessories (batteries) when necessary to maintain the hearing aid in
functional order
4.2.2 Exclusions
In-the-canal (ITC) hearing aides that are digital or programmable are not covered.
Instructions for ICS Provider Billing – Page 5
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4.2.3 Approval Needed
Members can directly access a hearing exam through a network provider. Care managers can
authorize hearing aids and items under $500 in cost that meet the ordering guideline criteria
referenced above and, if a care manager is unsure of the item, it should be reviewed by the care
management supervisor or clinical peer reviewer.
Items costing more than $500 require supervisory review to determine cost effectiveness and
medical necessity. Supervisors will consult with the clinical peer reviewer before a determination
is made.
ICS authorization required
MD order not required
4.2.4 Billing
Type of claim form: CMS 1500 (See page 27)
For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit:
https://www.emedny.org/ProviderManuals/HearingAid/index.aspx
4.3 Dental
4.3.1 What is Covered?
Routine, preventive dental examination and treatment once every six months such as
examinations / cleaning / gum scaling / x-rays
Restorative care such as fillings / bridgework / dentures
Dentures lost or damaged due to loss, fire, or theft can be replaced with appropriate
documentation.
4.3.2 Exclusions
Dental implants
4.3.3 Approval Needed
Member can self-refer to a network provider for routine bi-annual examination and emergent
care. Provider will request authorization for payment of any treatment (routine or non-routine) to
be provided resulting from the examination. Care managers can authorize the cost of the
treatment plan when it is less than $2,000 following the Medicaid fee-for-service coverage
guidelines. If the treatment plan cost is greater than $2,000, the plan must be reviewed by a
licensed dental consultant (prospective peer review) prior to authorization. The dental consultant
will use his/her professional clinical judgment and base his/her decision on generally accepted
professional guidelines.
ICS authorization required
MD order not required
Instructions for ICS Provider Billing – Page 6
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4.3.4 Billing
Type of claim form: ADA Dental Claim Form (See page 28) or CMS 1500.
For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit:
https://www.emedny.org/ProviderManuals/Dental/index.aspx
4.4 Durable Medical Equipment
4.4.1 What is Covered?
Devices and equipment needed in the treatment of a specific medical condition or used to
support functioning in activities of daily living. These include, but are not limited to:
Mobility devices including wheelchairs, walkers, canes, and scooters
Hospital beds
Bathroom equipment
Adaptive aids such as reachers
Repair of the above equipment
4.4.2 Coverage Criteria
Hospital Beds
ICS will cover the lease (rental) or purchase of a hospital bed to be used in a member’s home.
The decision to lease or purchase will be based on other insurance coverage policy, such as
Medicare, and any maintenance agreements with the supplier/manufacturer.
The standard hospital bed covered under the ICS policy is a semi-electric style bed. A semi-
electric bed has power operated controls for adjusting the head position and the foot position.
The height of the bed from the floor is manually adjusted via a hand crank, located at the foot of
the bed.
Hospital beds are 36” wide x 80” long (similar in size to a twin/single bed). Bed extensions are
available to increase the length to 86” long for members who are more than six feet tall.
A fully electric hospital bed has the added feature of power operated control to adjust the overall
height of the bed off the floor and is covered only if the member meets at least one of the
following criteria:
Requires adjustment of the height of the bed from the floor to safely complete
independent transfers;
Member weighs over 350 lbs;**
Member has a caregiver who is elderly or frail; or
Member has tried to use a standard, semi-electric bed and has functional limitations
due to the bed height feature being manually adjustable.
Instructions for ICS Provider Billing – Page 7
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** NOTE: A member who weighs over 350 lbs. will require the use of a bariatric bed.
Bariatric beds are 42” wide (6” wider than standard hospital beds). Because of the increased
weight capacity, the mattress on the bariatric bed is significantly firmer than a standard hospital
bed.
Specialty Mattress and Support Surfaces
ICS will cover payment of specialty mattresses and support surfaces for persons who have or are
at risk for the development of pressure sores. ICS follows the Medicare coverage criteria to
determine the type of support surface to be provided.
Mobility Devices – Ambulatory Aids and Wheelchairs
Mobility aids covered under the Medicare Competitive Bid Program – walkers and standard
manual and power wheelchairs and scooters – may be provided under Medicare guidelines if the
member is dually eligible with Part B Medicare coverage. Claims should be processed via
coordination of benefits.
ICS will provide authorization for an evaluation by a qualified health care provider – an
occupational or physical therapist – to determine the features and function of the mobility device
to best meet the member’s functional need.
ICS coverage policy of all mobility devices follows Medicare guidelines for mobility assistive
equipment (MAE), with the exception of the “in the home use, only” limitation. ICS will cover a
needed mobility device for both/either in home use and/or for community use. If the need for a
wheeled mobility device is only for community use, the claim can be submitted with a GY
modifier (known Medicare denial), along with documentation of a clinical assessment conducted
by a qualified health care provider (i.e., OT, PT).
For a member with complex rehab needs, the provider is encouraged to refer the member back to
ICS for a full seating and mobility assessment by a certified assistive technology professional
(ATP) to generate a recommendation as the result of a clinical assessment of both functional and
environmental needs.
Patient Lifts
ICS will cover payment for the use of a mechanical lift for members who are unable to be safely
transferred using either a stand-pivot method or assisted use of a transfer board. Lifts are either
leased (rented) or purchased depending on primary insurance coverage policy, length of need or
maintenance agreements with the supplier and/or manufacturer.
Members who are unable to safely perform a stand-pivot transfer with the assistance of a
personal care assistant (PCA) or a sliding board transfer will need to use a mechanical lift when
being transferred by a PCA.
The standard mechanical lift as defined by ICS coverage policy is a manually operated, hydraulic
lift with sling. All sling styles and attachment methods available on manually operated lifts will
be covered.
Instructions for ICS Provider Billing – Page 8
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A fully electric lift (power operated lifting arm) will be covered if the member meets the one of
the following criteria:
Member weighs over 300 lbs;
Caregiver is frail or elderly; or
A standard lift has been tried and the member has functional limitations due to the
lack of a power operated lifting arm.
For members who have never used a mechanical lift, an in-home physical therapy (PT)
evaluation will be needed to evaluate the member and the environment for the safe use of the lift.
If a lift is recommended, the PT will provide instruction to the PCA and family members on safe
and effective use of the lift.
A one-month rental of a patient lift will be authorized to have a lift available to the PT as part of
the evaluation.
4.4.3 Approval Needed
For dually eligible members with Part B coverage, no additional authorization is required from
ICS for a claim demonstrating coordination of benefits with Medicare Part B, requesting
payment of the Medicare 20% co-pay only.
For ICS payment the following is needed:
MD order is required
ICS authorization required – Authorization will be provided following submission of:
o Supplier quote (including pricing following Medicaid fee structure)
o Supporting documentation and justification by a qualified health care professional
that outlines the member’s need for the requested item if the item is not the least
costly alternative item to meet the need 4.4.4 Billing
Type of claim form: CMS 1500
For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit:
https://www.emedny.org/ProviderManuals/DME/index.aspx
Instructions for ICS Provider Billing – Page 9
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4.5 Home Care Aide Services
4.5.1 What is Covered?
Home health aides (HHAs) provided as part of a treatment plan administered by a
certified home health agency
Personal care aides (PCAs)
4.5.2 Exclusions
Home care aide hours should not be approved for time a member spends in an adult
day health program or dialysis treatment.
4.5.3 Approval Needed
Care manager includes the need for home care aide services on care plan and authorizes the type
and number of hours.
MD order required. Physician certifies the need for service, but does not determine
the number of hours, but may make a recommendation. No MD orders are needed for
housekeeping services.
ICS authorization required. The ICS authorization of hours and dates of service must
exactly match the hours and dates of service rendered by the service provider.
4.5.4 Billing
Type of claim form: UB-04
For Procedure Codes, please refer to the table on the following page:
Instructions for ICS Provider Billing – Page 10
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Home Care Procedure Codes Table
ICS Service Provided HCPCS Modifier 1 Modifier 2 Modifier 3 Notes
Home Health Aide S5125
Housekeeper -
Hourly T1019 1A
Housekeeper - One
Time Only T1019 1A 1D
1D Modifier used to distinguish
one time cleaning
Housekeeper - One
Time Only T1019 1A 1D 1J
1D Modifier used to distinguish
one time cleaning
1J Modifier used to distinguish
heavy duty cleaning
Personal Assistant T1019 1B 1B Modifier used to support PA
rate
Personal Assistant -
Mutual T1019 1B 1B Modifier used to support PA
rate
Personal Assistant -
Sleep In T1019 1B
1B Modifier used to support PA
rate
Personal Assistant -
Sleep In Mutual T1019 1B 1M
1B Modifier used to support PA
rate
1M Modifier used to support
reduced (half) daily rate
Personal Care Aide T1019
Personal Care Aide -
Mutual T1019
Personal Care Aide -
Sleep In T1019
Personal Care Aide -
Sleep In Mutual T1019 1M
1M Modifier used to support
reduced (half) daily rate
Personal Care Aide
BFL Cluster T1019 1I
1I Modifier used to support
different rate (CHCA contract
only)
Please refer to conditions on following page:
Instructions for ICS Provider Billing – Page 11
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* Please use hourly rate: Please convert all 15 minute increments into an hourly rate (i.e. If you
are billing one unit, we will process it as one hour, not as a 15 minute increment).
1. All mutual cases shall be billed at the hourly rate multiplied by the number of hours spent
caring for each members
2. All sleep-in cases for dates of service of 5/1/2014 and later will require HCPCS code
T1020 to be billed instead of HCPCS code T1019. The rate billed should be the hourly
rate multiplied by 12 hours. The total amount (hourly rate X 12) should be billed as one
unit.
3. All sleep-in mutual cases for dates of service as of 5/1/2014 and later will require HCPCS
code T1020 to be billed instead of HCPCS code T1019. The rate billed should be the
hourly rate multiplied by six hours. The total amount (hourly rate X six hours per
member) should be billed as one unit.
4.5.5 Home Care Modifier Definitions
Housekeeping 1A
Personal Assistant 1B
One Time Only 1D
Heavy Duty 1J
Sleep in Mutual (1/2 rate) 1M
CHCA Contract Rate
Please Use modifier for
add on dishes
1L
4.5.6 Fee Schedule
Please refer to your ICS contract.
4.6 Home Delivery of Meals
4.6.1 What is Covered?
Home delivered meals are provided when the need is indicated in a member’s plan of
care.
Members who need assistance with meal preparation (i.e., cannot cook, are not safe
cooking, have no cooking facilities) and have less than four hours per day of home
care service are eligible for one meal per day to be delivered.
Under special circumstances (e.g., PCA is unable to prepare special dietary
requirements to address nutritional changes), a member may receive two (2) meals
daily for a limited time.
4.6.2 Exclusions
None
4.6.3 Approval Needed
Instructions for ICS Provider Billing – Page 12
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ICS authorization required
MD order not required
4.6.4 Billing
Type of claim form: Please use CPT code S5170 on a CMS 1500 Form.
Side orders should be billed with modifier (SO).
4.6.5 Fee Schedule
Please refer to your ICS contract.
4.7 Medical Supplies
4.7.1 What is Covered?
Medical supplies and items for health use other than medications, prosthetic and orthotic devices
and durable medical equipment that are used in the treatment of a specific medical condition and
which are consumable, non-reusable, disposable.
These include but are not limited to:
Diabetic supplies, if not provided by a pharmacy plan
Dressing and other wound care supplies
Urinary catheters
Incontinence supplies (e.g., disposable underwear/briefs/underpads)
Nutritional supplements such as Ensure
4.7.2 Approval Needed
As long there is a medical necessity for ordering the supplies referenced they will be ordered.
MD order required
ICS authorization required
4.7.3 Billing
Type of claim form: CMS 1500
For Procedure Codes and Billing Guidelines, please visit:
https://www.emedny.org/ProviderManuals/DME/index.aspx
Instructions for ICS Provider Billing – Page 13
April 2015
4.8 Nursing Home Care
4.8.1 What is Covered?
Post-acute care, short-term rehabilitation, respite care, and long-term custodial care in a skilled
nursing facility licensed by the New York State Department of Health.
Nursing home per diem rates cover: Semi-private room and board
Nursing and personal care services, including assistance with all activities of daily
living
Rehabilitation services
Recreational and socialization activities
Maintenance of the member’s room
Other facility-related services
4.8.2 Exclusions
Members who express a preference to be placed in a non-network nursing facility for
a long-term care placement with no intent to return to community living
4.8.3 Approval Needed
MD order required (The nursing home will usually get the MD order directly)
ICS authorization required
4.8.4 Billing
For Procedure Codes, Billing Guidelines, please visit:
https://www.emedny.org/ProviderManuals/ResidentialHealth/PDFS/ResidentialHealth_Billing_
Guidelines_UB04.pdf
4.8.5 Fee Schedule
Please refer to your ICS contract.
4.9 Nutrition Services
4.9.1 What is Covered?
Assessment by a qualified nutritionist of the nutritional status, food preferences, and
need for therapeutic diets
Nutritional education as part of a treatment plan
4.9.2 Exclusions
None
Instructions for ICS Provider Billing – Page 14
April 2015
4.9.3 Approval Needed
Members can self-refer for one wellness evaluation per year within the provider network.
Recommended treatment plans submitted by the qualified nutritionist will be authorized by care
manager for members meeting clinical and diagnostic criteria referenced above.
ICS authorization required
MD order not required
4.9.4 Billing
Type of claim form: UB-04 or CMS 1500
4.9.5 Fee Schedule
Please refer to your ICS contract.
4.10 Optometry Services
4.10.1 What is Covered?
Optometry services (eye exams, eyeglasses, contact lenses) are covered. This includes:
Annual eye exams to detect visual defects and eye disease
Prescription lenses ($50 per lens) and up to $100 for eyeglass frames every two (2)
years
Replacement of lost, stolen or damaged glasses with documentation
Low vision aids
Low vision services
4.10.2 Exclusions
Members with neurological problems, acute vision loss, elevated IOP, suspicious optic
nerves, diabetic retinopathy or cataracts, should be referred to an ophthalmologist.
Contact lenses and tinted lenses are not covered when prescribed for cosmetic
reasons only.
4.10.3 Approval Needed
Members can self-refer for exam from a network provider. Items and services under $500 are
authorized following Medicaid fee-for-service guidelines. Items greater than $500 require
supervisor’s review and any recommendation to deny is reviewed by a clinical peer reviewer
utilizing professional clinical judgment and low vision standards of care.
ICS authorization required
MD order not required
Instructions for ICS Provider Billing – Page 15
April 2015
4.10.4 Billing
Type of claim form: CMS 1500
For Procedure Codes and Billing Guidelines, please visit:
https://www.emedny.org/ProviderManuals/VisionCare/index.aspx
4.11 Personal Emergency Response System (PERS)
4.11.1 What is Covered?
An electronic device worn by a member to secure help in the event of a physical, emotional, or
environmental emergency. This includes:
Installation of equipment
Monitoring of equipment
Console unit, two personal care activators, and a smoke detector
4.11.2 Exclusions
Member is no longer living at home (e.g., nursing home, transitional housing)
Members who receive 24-hour care or have a reliable caregiver present in home
Members who have shown significant improvement in condition and no longer need
PERS
4.11.3 Approval Needed
MD order required
ICS authorization required
4.11.4 Billing
Type of claim form: UB-04 or CMS 1500
For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit:
https://www.emedny.org/ProviderManuals/PERS/index.aspx
4.11.5 Fee Schedule
Please refer to your ICS contract.
Instructions for ICS Provider Billing – Page 16
April 2015
4.12 Podiatry
4.12.1 What is Covered?
Routine foot care, such as treatment of corns and calluses, trimming of nails, hygienic
care such as soaking or cleaning feet
Non-routine care such as: 1. Diagnosis and treatment of any illness or injury in the foot, such as infection or
fungus
2. Incisions
3. Excisions
4. Removal of foreign objects
5. Repair or suture of tendons, foot, flexor
6. Treatment of dislocations
4.12.2 Exclusions
None
4.12.3 Approval Needed
MD order not required
ICS authorization required
4.12.4 Billing
Type of claim form: CMS 1500
For Procedure Codes, Billing Guidelines, please visit:
https://www.emedny.org/ProviderManuals/Podiatry/index.aspx
4.13 Rehabilitation Services
4.13.1 What is Covered?
Rehabilitation services include physical, occupational, and speech therapies provided in a
licensed rehabilitation facility or through a certified home health agency.
Physical therapy services include examination, diagnosis, and treatment of
musculoskeletal and neuromuscular impairments resulting in functional limitations.
Occupational therapy includes evaluation of performance, skills assessment, and
treatment customized to improve ability to perform activities of daily living.
Speech therapy includes evaluation and treatment of slurred speech, breath control,
voice issues, aphasia, stuttering, swallowing difficulties and augmentative
communication needs.
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4.13.2 Approval Needed
Network therapists will submit recommended treatment plans for peer review and approval for
the authorization. The member’s care management coordinator (CMC), who supports the
member’s assigned team, will forward any recommendation for approval for authorization to a
clinical peer reviewer for a decision based on professional clinical judgment and professional
standards of care.
MD order required
ICS authorization required
NOTE: Network providers are encouraged to call ICS 1-877-ICS-2525 (877-427-2525) and
request to speak to the CMC supporting the member’s assigned team to determine if the member
has recently received services from another provider within the calendar year, prior to drafting
a treatment plan that may not be authorized.
4.13.3 Billing
Type of claim form: CMS 1500
For Procedure Codes, Billing Guidelines, please visit:
https://www.emedny.org/ProviderManuals/RehabilitationSrvcs/index.aspx
4.13.4 Fee Schedule
Please refer to your ICS contract.
4.14 Respiratory Services
4.14.1 What is Covered?
The performance of preventive, maintenance and rehabilitative airway-related techniques and
procedures. Includes:
Application of medical gases
Humidity and aerosols
Intermittent positive pressure
Continuous artificial ventilation
Administration of drugs through inhalation and related airway management
Patient care
Patient teaching
4.14.2 Exclusions
None
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April 2015
4.14.3 Approval Needed
All MD orders for respiratory services are followed and implemented. Care manager
authorization of equipment as part of care plan; service component is part of contractual
agreement with equipment provider.
ICS authorization required
MD order required
4.14.4 Billing
Type of claim form: CMS 1500
4.14.5 Fee Schedule
Please refer to your ICS contract.
4.15 Skilled Home Health Care Services (Skilled RN, LPN, MSW Services)
4.15.1 What is Covered?
Home health care includes skilled services that are of a preventive, therapeutic, or health
teaching nature. This includes: Skilled nursing services
Medical social services
Home infusion (chemotherapy, intravenous feedings)
Skilled nursing includes both registered (RN) and licensed practical nursing (LPN) care arranged
(by contract) through certified home health agencies, licensed agencies, or nursing registries.
Medical social services describe the psychosocial assessment and treatment planning offered by
qualified social workers and social work assistants.
4.15.2 Exclusions
None
4.15.3 Approval Needed
MD order required (Certified home health agency will obtain MD orders separately.)
ICS authorization required
4.15.4 Billing
Type of claim form: UB-04 or CMS 1500
4.15.5 Fee Schedule
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April 2015
Please refer to your ICS contract.
4.16 Social Day Care
4.16.1 What is Covered?
Social day programs provide special recreational and therapeutic activities designed to provide
socialization. Service highlights include: Arts and crafts
Physical activities
Music and singing
Cooking
Discussion groups
Parties and holiday events
Diverse cultural programs
Snacks and lunch
4.16.2 Exclusions
None
4.16.3 Approval Needed
ICS authorization required
MD order not required
4.16.4 Billing
Type of claim form: UB-04 or CMS 1500
4.16.5 Fee Schedule
Please refer to your ICS contract.
4.17 Transportation
4.17.1 What is Covered?
Non-emergency transportation (e.g., public transportation, Access-A-Ride, car service,
ambulette, or ambulance) to medical appointments or adult or social day program activities that
are part of the member’s care plan.
4.17.2 Exclusions
Transportation to non-medical appointments that are not authorized by care management
as part of the care plan.
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April 2015
4.17.3 Approval Needed
Once level of transportation is authorized by care manager, members can arrange
transportation to medical or day program appointments directly or via the Member
Services Center.
MD order not required
4.17.4 Billing
Type of claim form: CMS 1500 only
For procedure codes and billing guidelines please visit
https://www.emedny.org/ProviderManuals/Transportation/index.aspx
For Transportation Codes with HCPCS/modifiers, please refer to the table on the following page.
4.17.5 Fee Schedule
Please refer to your ICS contract.
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April 2015
Transportation Codes with HCPCS / Modifiers
Service Code: Ambulette
HCPCS Code HCPCS
Code HCPCS Code
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
T2003 T2003 T2003
Service Code: Ambulance with Basic Life Support
HCPCS Code HCPCS
Code HCPCS Code
A0428 A0428 A0428
A0428 A0428 A0428
A0428 A0428 A0428
A0428 A0428 A0428
A0428 A0428 A0428
A0428 A0428 A0428
Service Code: Ambulance with Advanced Life Support
HCPCS Code HCPCS
Code HCPCS Code
A0426 A0426 A0426
A0426 A0426 A0426
A0426 A0426 A0426
A0426 A0426 A0426
A0426 A0426 A0426
A0426 A0426 A0426
Service Code: Livery
HCPCS Code HCPCS
Code HCPCS Code
A0100 A0100 A0100
A0100 A0100 A0100
A0100 A0100 A0100
For detailed instructions, please refer to
https://www.emedny.org/ProviderManuals/Transportation/PDFS/Transportation_Billing_Guideli
nes.pdf.
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Section 5: Standard Form Samples
5.1 UB-04 Sample Claim Form
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5.2 CMS 1500 Sample Claim Form
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April 2015
5.3 Dental Sample Claim Form