does patient can have both Medicare advantage plan and Medigap policy?

Medicare Advantage Plans

Medicare Advantage Plans include the following:

• Preferred Provider Organization (PPO) Plans

• Health Maintenance Organization (HMO) Plans

• Private Fee-for-Service (PFFS) Plans

• Medical Savings Account (MSA) Plans

• Special Needs Plans (SNP)

Medicare Advantage Plans and Medigap Policies 

Important: If you have a Medigap policy and you are switching from Original Medicare to a Medicare Advantage Plan, you don’t need and can’t use the Medigap policy to cover deductibles, copayments, or coinsurance under the Medicare Advantage Plan. You may choose to drop your Medigap policy, but you should talk to your State Health Insurance Assistance Program and your current Medigap insurance company before you do because you may not be able to get it back. If you already have a Medicare Advantage Plan, it is illegal for anyone to sell you a Medigap policy unless you are switching back to Original Medicare

Medicare Prescription Drug Coverage (Part D)

Medicare offers prescription drug coverage (Part D) for everyone with Medicare. To get Medicare drug coverage, you must join a plan run by an insurance company or other private company approved by Medicare. Each plan can vary in cost and drugs covered. If you want Medicare drug coverage, you need to choose a plan that works with your health coverage. Th ere are two ways to get Medicare prescription drug coverage:

1. Medicare Prescription Drug Plans. These plans (sometimes called “PDPs”) add drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-for-Service Plans, and Medicare Medical Savings Account Plans.

2. Medicare Advantage Plans (like an HMO or PPO) or other Medicare health plans that have prescription drug coverage. You get all of your Part A and Part B coverage, including prescription drug coverage (Part D), through these plans. Medicare Advantage Plans with prescription drug coverage are sometimes called “MA-PDs.”

What is original medicare and different type of Medicare plans

What is Medicare?

Medicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant). Original Medicare covers many health care services and supplies, but there are many costs (“gaps”) it doesn’t cover.

The Different Parts of Medicare

The different parts of Medicare help cover specific services if you meet certain conditions. Medicare has the following parts:

Medicare Part A (Hospital Insurance) 

• Helps cover inpatient care in hospitals

• Helps cover skilled nursing facility, hospice, and home health care

Medicare Part B (Medical Insurance)

• Helps cover doctors’ services and outpatient care

 • Helps cover some preventive services to help maintain your health and to keep certain illnesses from getting worse

Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO)

•A health coverage choice run by private companies approved by Medicare 

• Includes Part A, Part B, and usually other coverage including prescription drugs

What is Skilled Nursing?

A Home Health Agency in the State of Wisconsin is defined as “an organization that primarily

provides both skilled nursing and other therapeutic services to patients in their homes,” according to Wisconsin Administrative Code, HFS 133.02.

Important Background Information Regarding “Skilled Level” Patients:

There are certain conditions that must be met for a patient to qualify for skilled home health services under Medicare, Medicaid, and some insurance companies; they are:

• Be confined to the home (homebound);

• Be under the care of a physician;

• Receive services under a plan of care established and periodically reviewed by a physician;

• Be in need of skilled nursing care on an intermittent basis or need physical therapy or speech

therapy;

• Have a continuing need for occupational therapy Clarification of Homebound:

This does not mean the patient must never leave their home. In general terms, a patient is considered “home bound” if they:

• Have a medical condition or an injury that restricts their ability to leave their home unless

they use an assistive device (crutches, cane, wheelchair, walker);

• Require the use of special transportation;

• Require the assistance of another person;

• Or, leaving their home is not medically advised

Patients may leave their homes occasionally; for church services, hairdressing, attending a family

functions while being driven in a vehicle by another person. Absences from the home to receive

medical treatments are also allowed, such as:

• attending adult day centers (licensed by the State of Wisconsin) to receive medical care;

• kidney dialysis;

• chemo/radiation therapy;

• and outpatient physical therapy, including whirlpool therapy

Obtaining a Home Health Agency License:

During the time an agency holds a Wisconsin provisional license, they are required to serve at least 10 skilled level patients requiring skilled nursing or other skilled services (physical, occupational, or speech therapy). Out of these 10 skilled level patients, at least 7 must require skilled nursing services.

Clarification of Skilled Nursing Duties:

A skilled nursing patient is one who requires the skills of a Registered Nurse. The registered nurse is responsible for:

• making the initial evaluation visit to the patient,

• reevaluating their needs regularly,

• initiating and revising the nursing plan of care,

• providing the services that require more specialized nursing care,

• planning for preventative and rehabilitative care,

• preparing clinical notes and informing physicians and others participating in the patient’s care

of changes as they occur.

According to the Medicare Benefit Manual, 30.4, (Medicare reimbursement) “skilled nursing care

must be reasonable and necessary, needed on an intermittent basis, and not be solely needed for

venipunctures for the purposes of obtaining blood samples.”

Some examples of patients who would qualify for skilled nursing care:

• Patients who require intravenous and intramuscular injections

• Patients needing Foley catheter insertions

• Patients with pre-existing peripheral vascular or circulatory disease (needing observation for

complications, pain management, teaching related to skin care, preservation of skin integrity,

and prevention of skin breakdown)

Resubmision claim or corrected claim check list

Are you going to resubmit the claim, make sure all the below points has been reviewd.

Resubmission Checklist

Use the following checklist to ensure that resubmittals are completed correctly before submitting.


*  Did you wait thirty days after the original submittal before resubmitting a missing claim?

* If using a photocopy of a claim, did you make sure it was legible and properly aligned?

* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?

*  If you have corrected or changed the original claim form, have strike overs been corrected on each copy? (Do not use whiteout.)

*  Has the resubmitted claim been signed again and dated?

How secondary claims are processed by insurance

When the Recipient Has Other Insurance

Introduction 

If the recipient has other insurance coverage, Medicaid payment will be denied unless the provider indicates receipt of a third party payment or attaches a denial from the other insurance company or documentation that the other insurance company will not cover the service.

Note: See Chapter 1 of the Florida Medicaid Provider General Handbook for information about third party liability (TPL).

Insurance Information on the Remittance Voucher

If the recipient has other insurance, the third party carrier code appears on the remittance voucher underneath the denied claim.

Note: A list of third party carrier codes and carrier billing information can be obtained from the Medicaid fiscal agent’s website at http://floridamedicaid.acs-inc.com or from the fiscal agent’s field representatives.

The field representatives’ phone numbers are listed on the last page of this chapter.

How claim are processed by insurance - paid or denied

Level of Claims Processing

Paper Claim Handling

When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the

provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.

Claim Entry 

Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.

Claim Adjudication 

FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.

Special Billing For Medically Needy Recipients

Introduction 

A Medically Needy recipient is an individual who would qualify for Medicaid,except that the individual’s income or resources exceed Medicaid’s income or resource limits. On a month-by-month basis, the individual’s medical expenses are subtracted from his or her income. If the remainder falls below Medicaid’s income limits, the individual may qualify for Medicaid for the month or for part of the month. The amount of expenses that must be deducted from the individual’s income to make him or her eligible for Medicaid is called a “share of cost.”

Medically Needy recipients can receive targeted case management services. Medically Needy recipients are not eligible to receive home and community based  waiver services.

Split Billing and CF-ES 2902 Form

If a recipient incurred medical expenses from multiple providers on the date he

met his share of cost (first day of eligibility), any medical expenses from a single provider that were used in full to meet the share of cost are not eligible for Medicaid reimbursement. Any expenses from a single provider that were not used in full to meet the share of cost are eligible for reimbursement. This process, known as “split billing,” is actually split-day billing—no individual

claims are split and no claims from a single source are split. This process occurs infrequently.

If not all of the recipient’s medical expenses incurred on the first day of eligibility are eligible for Medicaid reimbursement, the MEVS split bill indicator will be “Y.” The public assistance specialist will mail a pink copy of the Medically Needy Billing Authorization, CF-ES 2902 Form, to the providers whose expenses are  eligible for reimbursement. Providers must submit the CF-ES 2902 Form with their claims so the Medicaid fiscal agent will know that the claims are eligible for reimbur sement.

If the MEVS split bill indicator is “N,” then all the recipient’s expenses incurred on the first day of eligibility are eligible for reimbursement and a CF-ES 2902 Form is not required.

 

Receiving a CF-ES 2902 Form

When a provider receives a pink copy of a CF-ES 2902 Form, the provider must check the bottom right-hand corner of the form, under the caption “Period of  Eligibility,” and make sure that the dates of service on the claim fall within the recipient’s period of eligibility.

If the service was performed on the first day of eligibility indicated on the CF-ES 2902 Form, the form must be submitted with the claim. If the service dates are after the first day of eligibility, the form does not need to be submitted with the claim.

what is claim certification in Medical billing

Claim Certification 

Because an electronic claim cannot be submitted with a signature, the provider’s endorsed signature on the back of the remittance check issued by the Medicaid fiscal agent takes the place of a signature on a paper claim form. It acknowledges the submission of the claim and the receipt of the payment for the claim. It certifies that the claim is in compliance with the conditions stated on the back of the paper claim form, and with all federal and state laws.

Any provider who utilizes the electronic funds transfer system is certifying with each use of the system that the claim(s) for which the provider is being paid is in compliance with the provisions found on the back of the paper claim form and with all federal and state laws.

Technical Support 

The Electronic Data Interchange (EDI) Support Unit assists providers who have questions about electronic claims submission. The fiscal agent’s EDI Technical Support is available to all providers Monday through Friday from 8:00 a.m. to 7:00 p.m. ET at 800-829-0218.

EDI Support will:

·  Provide information on available services.

·  Assist in enrolling users for electronic claims submission and report retrieval.

·  Process test transmissions.

·  Provide technical assistance on transmission difficulties.

Note: Information on EDI is available on the fiscal agent’s website at http://floridamedicaid.acs-inc.com.

Electronic Claims Submission - introduction and benefits - can we use free software?

Introduction

Submitting Medicaid claims via electronic media offers the advantage of speed and accuracy in processing. Providers may submit electronic claims themselves or choose a billing agent that offers electronic claim submission services. Billing agents must enroll as Medicaid providers.

Benefits

 The benefits of electronic claims submission include:
·  Increase speed of claims payments, seven days in some cases.
·  Correct data entry errors immediately, avoiding mailing time and costs.
·  Eliminate the cost and inconvenience of claims paperwork.
·  Reduce office space required for storing claim forms, envelopes, etc.
·  Decrease mailing costs.
·  Decrease clerical labor costs.
·  Automate the office for a more efficient operation.


Free Software 

The Medicaid fiscal agent has PC-based software, called WINASAP 2003, which enables providers to submit claims electronically on IBM compatible personal computers (PC) in their offices.

Providers can transmit the claims via telephone lines directly to the Medicaid fiscal agent.

How to report Chiropractic Manipulative Treatment

CMT is a form of manual treatment to influence joint and neurophysiological function.

When similar or identical procedures are performed, but are qualified by an increased level of complexity:

• Only the definitive or most comprehensive service performed should be reported
• Only one CMT service of the spinal region (procedures 98940-98942) or extraspinal region (98943) is eligible for payment on a single date of service.
• Payment is limited to one clinically indicated and medically necessary physical medicine modality or procedure code per patient, per date of service.
• Payment is allowed for one clinically indicated and medically necessary extraspinal manipulation code (i.e., 98943-51) in combination with a spinal manipulation code (i.e., 98940, 98941, or 98942) per date of service.

The chiropractic manipulative treatment codes include a pre-manipulation patient assessment. Additional E/M services may be reported separately using modifier 25, if the member’s condition requires a significant separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure. 

insurance claims submission and mailing checklist

Claims Submission Checklist
Introduction 

Use the following checklist before submitting a claim to the fiscal agent for reimbursement.

Checklist

* Is the form typed or printed in black ink?
*  Is the copy legible?
* Were instructions in the handbook followed? Some fields are not self explanatory or may be used for other purposes.
* Are the provider name(s) and number(s) entered?
* Is the claim signed and dated? Unsigned claims will be returned unprocessed.
* Are attachments required? Claims cannot be paid without the required attachments.
*  Is the P.O. Box number for submitting the claim correct?


Claims Mailing Checklist
Introduction The following checklist may be used when mailing claims to the fiscal agent for
reimbursement.

Checklist

* Enclose only one claim type per envelope. Claims and adjustment requests should be sent separately because they are processed separately by the fiscal agent.

claim timely filing denial exceptions.

The following scenario, claim will not be denied as timely filing limit exceeded.
Exceptions to the 12-Month Time Limit
Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:

·  New clean claim submitted within six months of the date of the void of the original claim payment date;
·  Court or hearing decision;
·  Delay in recipient eligibility determination;
·  Medicaid delay in updating eligibility file;
·  Court ordered or statutory action; or 

·  System error on a claim that was originally filed within 12 months from the date of service.


Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent.

Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six months from the void date.


Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.


Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must include:
·  A clean claim,
·  A copy of the recipient’s proof of eligibility, and
·  Documentation of the reason for late submission.

Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.

Medicaid claim submission time limit - primary and secondary claims

Timely Claim Submission
Medicaid providers should submit claims immediately after providing services so that any problems with a claim can be corrected and the claim resubmittedbefore the filing deadline.

Clean Claim 
In order for a claim to be paid, it must be a clean claim. A clean claim is a Medicaid claim that:
·  Has been accurately and fully completed according to Medicaid billing guidelines.
·  Is accompanied by all necessary documentation.
·  Can be processed and adjudicated by the fiscal agent without obtaining additional information from the provider.


12-Month Filing Limit
A clean claim for services rendered must be received by the Medicaid office or its fiscal agent no later than 12 months from the date of service.

Date Received Determined

The date stamped on the claim by any Medicaid office or by the Medicaid fiscal agent is the recorded date of receipt for a paper claim. The fiscal agent date stamps the claim the date that it is received in the fiscal agent’s mail room.
The date electronically coded on the provider’s electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.

New and Established CPT code list

New and Established Patient Services 


A new patient is one who has not received any professional services from a physician or from another physician of the same specialty who belongs to the same group practice, within the past three years. Providers must use procedure codes 99201, 99202, 99203, 99204, and 99205 when billing for new patient services provided in the office or an outpatient or other ambulatory facility. New patient visits are limited to one every three years, per client, per provider. 

An established patient is one who has received professional services from a physician or from another physician of the same specialty within the same group practice, within the last three years. Providers must use procedure codes 99211, 99212, 99213, 99214, and 99215 when billing for established patient services provided in the office or an outpatient or other ambulatory facility: 

When an office visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, the office visit must be billed as an established patient visit. If a new patient visit is billed with the same date of service as a THSteps medical checkup or exception to periodicity visit, then the new patient visit will be denied. 

Modifier 25 may be used to identify a significant, separately identifiable E/M service performed by the same physician on the same day as another procedure or service. Documentation that supports the provision of a significant, separately identifiable E/M service must be maintained in the client's medical record. The documentation must clearly indicate what the significant problem/abnormality was, including the important, distinct correlation with signs and symptoms to demonstrate a distinctly different problem that required additional work and must support that the requirements for the level of service billed were met or exceeded. 

The date and time of both services performed must be outlined in the medical record and the time of the second service must be different than the time of the first service, although a different diagnosis is not required. 

An established patient visit that is billed with the same date of service as a new patient visit by the same provider will be denied as part of another procedure except when the established patient visit is billed with a new THSteps medical checkup. 

Office visits (procedure codes 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, and 99215) provided on the same date of service as a planned procedure (minor or extensive) are included in the cost of the procedure and are not separately reimbursed. 

Office visit procedure code 99211, 99212, 99213, 99214, or 99215 must be billed by the same provider with the same date of service as a group clinical visit. 

New CLIA waived CPT list - 2012

New Waived Tests 

Effective Date : January 1, 2012

Implementation Date : January 3, 2012

STOP- Impact to you

If you do not have a valid, current, Clinical Laboratory Improvement Amendments of 1998 (CLIA) certificate and submit a claim to your Medicare Carrier or A/B MAC for Current Procedural Terminology (CPT) code that is considered to be a laboratory test requiring a CLIA certificate, your Medicare payment may be impacted.

CAUTION _ What you need to know

CLIA requires that for each test it performs, a laboratory facility must be appropriately certified. The CPT codes that the Centers for Medicare & Medicaid Services (CMS) considers to be laboratory tests under CLIA (and thus requiring certification) change each year. Change Request (CR) 7566, from which this article is taken, informs carriers and MACs about the latest new CPT codes that are subject to CLIA edits.

GO – What you need to do

Make sure that your billing staffs are aware of these CLIA-related changes for 2012 and that you remain current with certification requirements.

Listed below are the latest tests approved by the Food and Drug Administration (FDA) as waived tests under CLIA. The CPT codes in the following table must have the modifier QW to be recognized as a waived test. However, CPT codes 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651 do not require a QW modifier to be recognized as a waived test.

CPT Code	Effective Date	Description
81003QW	14-Feb-11	Germaine Laboratories Inc. AimStrip Urine Analyzer
G0434QW	22-Apr-11	UCP Biosciences, Inc. UCP Drug Screening Test Cups
G0434QW	22-Apr-11	Diagnostic Test Group Clarity Multiple Drug Screen Test Cups
81003QW	24-Mar-11	Mediwatch urinewatch Urine Analyzer
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cassette Test
G0434QW	17-Jun-11	Insight Medical Drug of Abuse Urine Cup Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Instant Technologies, Inc. iScreen Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Jant Pharmacal Accutest Drug of Abuse Urine (Cup) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cassette) Test
G0434QW	17-Jun-11	Total Diagnostic Solutions Drug of Abuse Urine (Cup) Test
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Simple Drug Screening Cups
G0434QW	30-Jun-11	Diagnostic Test Group Clarity Multi-Drug Test Cards
81003QW	14-Jul-11	Stanbio Uri-Trak 120 Urine Analyzer
G0434QW	21-Jul-11	UCP Biosciences, Inc. U-Checker Drug Screening Test Cups