Medicare HMO denied the claim as covered by hospice

Claims From Medicare Advantage Organizations

Federal regulations require that Medicare fee-for-service contractors maintain payment responsibility for managed care enrollees who elect hospice. These regulations are found that Medicare Fee for Service retains payment responsibility for all hospice and non-hospice related claims beginning on the date of the hospice election.

A - Covered Services

While a hospice election is in effect, certain types of claims may be submitted by either a hospice provider, or a provider treating an illness not related to the terminal condition, to a fee-for-service contractor of CMS. These claims are subject to the usual Medicare rules of payment, but only for the following services:

1. Hospice services covered under the Medicare hospice benefit if billed by a Medicare hospice;

2. Services of the enrollee’s attending physician if the physician is not employed by or under contract to the enrollee’s hospice;

Molina covered Vaccines list

Vaccines for Recipients Birth through (18) Years 

For eligible recipients from birth through (18) years of age, vaccines and combination vaccines providing protection against the following diseases are available free to the VFC-enrolled provider through the VFC program:

  Diphtheria, Tetanus and Pertussis (DTaP)

  Haemophilus Influenzae Type b (HIB)

  Hepatitis B (pediatric and adult)

  Meningococcal Conjugate (MCV4)

  Pneumococcal (PCV 7)

  Polio (IPV)

  Measles, Mumps, and Rubella (MMR)

  Tetanus and Diphtheria (Td) (Adult)

  Influenza

  Varicella

  Human Papillomavirus (HPV)

  Rotavirus

The following vaccines are available by request or for high-risk areas only through the VFC program:

  Hepatitis A

  Diphtheria and Tetanus (DT) (Pediatric)

  Pneumococcal Polysaccharide (PPV)

  Meningococcal Polysaccharide (MPSV4)

Vaccines for Recipients (19) through (20) Years

For eligible recipients ages (19) through (20) years, vaccines and combination vaccines providing protection against the following diseases are reimbursable:

  Hepatitis A

  Hepatitis B

  Human Papillomavirus (HPV)

  Influenza

  Measles, Mumps, and Rubella (MMR)

  Meningococcal Conjugate (MCV 4)

  Meningococcal Polysaccharide (MPSV4)

  Pneumococcal Polysaccharide (PPV)

  Tetanus and Diphtheria (Td)

  Varicella

Process involving change of ownership with Medicare

Provider Change of Ownership

Providers (as defined in 1861(u) of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners.  They are also required to inform CMS on how they will organize the new entity and when the change will take place.  A terminating cost report will be required from the seller owner in all CHOWs for certification purposes.  There are five types of changes that can occur: 

1.   A CHOW in accordance with 42 CFR 489.18; 

2.   Changes in the ownership structure to an existing provider that do not constitute a CHOW;  

3.   A new owner who purchases a participating provider but elects not to accept the automatic assignment of the existing provider agreement, thus avoiding the old owner’s Medicare liabilities; 

4.   An existing provider who acquires another existing provider (acquisition/merger); and  

5.   Two or more existing providers who are totally reorganizing and becoming a new provider (consolidation). 

Providers that undergo a change of ownership will usually continue with the same FI that served the previous owner.  However, if the prospective owner does not wish to accept the automatic assignment of the existing provider agreement, this means that the existing provider agreement is terminated effective with the CHOW date.  The regional office must be notified in writing of the CHOW per instructions contained in section 3210.5 of the State Operations Manual. The prospective owner provides a notice 45 -days in advance of the CHOW to the CMS/RO to allow for the orderly transfer of any beneficiaries that are patients of the provider.  All reasonable steps must be taken to ensure that beneficiaries under the care of the provider are aware of the prospective termination of the agreement.  There may be a period when the facility is not participating and beneficiaries must have sufficient time and opportunity to make other arrangement for care prior to the CHOW date.

Claims Processing Requirements for Medicare Deported Beneficiaries

Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation.  Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit payable under Title II.  Section 1836 of the Act limits Part B benefits to those who are either entitled to Part A benefits or who are age 65 and a United States (U.S.) resident, U.S. citizen, or a lawfully admitted alien residing permanently in the U.S.  Given that, a deported beneficiary is not allowed to enter the U.S. and cannot be lawfully present in the United States to receive Medicare-covered services, Medicare payment cannot be made for Part B Benefits.

An audit of Medicare payments by the Office of Inspector General identified a vulnerability for the Medicare trust fund with respect to this issue.  The study identified improper payments for beneficiaries, who, on the date of service on the claim, had been deported.  To address this vulnerability, CMS is establishing claim level editing using data from the Social Security Administration (SSA).  Specifically, the data contains the name and Health Insurance Claim (HIC) of the Medicare beneficiary and the month the deportation is effective.  CWF will reject claims where the effective date on the Master Beneficiary Record is equal to or greater than the date of service on the claim.  All claims rejected by CWF shall be denied by the respective Carrier, DMERC, RHHI or intermediary that submitted the claim to CWF. 

PSYCHCARE TRIAGE AND REFERRAL PROCESSES

Our  clinical  philosophy  is  to  provide  the  most  appropriate  member/practitioner  match  and  the  least  restrictive treatment intervention for each member's needs across the life cycle. Our clinical orientation is a biopsychosocial approach  with  emphasis  on  wellness,  early  intervention,  and  integration  of  behavioral  and  medical  healthcare. Excellent outcomes are maximized by good partnerships and a clinical consultation approach with all clinicians that deliver services to our members. 

Psychcare  makes  decisions  whether  to  approve  or  not  approve  payment  for  services  based  only  on  the appropriateness of the care or service, and what the member’s benefit plan covers.  

The Medical Director oversees all triage and referral decisions. The Medical Director is available 24 hours per day; 7 days per week, to consult on initial clinical review decisions, and conduct peer clinical review.  

The Vice President of Clinical Operations supervises nonurgent pre-service processes, and initial clinical review processes. The Vice President of Clinical Operations is available 24 hours per day, 7 days per week, to consult with Case Managers on initial clinical review decisions  

Emergency Referrals 

In the event a patient is experiencing a behavioral health emergency in your office, or contacts you in crisis, call the police. If your patient can be safely transported with support, route the member to the nearest emergency room. After ensuring that the patient is safe, call Psychcare 24 hours per day, 7 days a week at (800) 221-5487 so that we can obtain the clinical information and begin managing the case.  

ICD 10 - Frequently asked question

1.  Q: What is ICD-10? 

A: ICD-10 is the International Classification of Diseases, version 10.  (ICD is the international standard for diagnostic classifications.) The current version, ICD-9, was adopted in 1979. 

2.  Q: What changes are occurring in the ICD-10 version? 

A: The changes will impact ICD-9-CM diagnosis codes and ICD-9-CM procedure codes.  The changes are as follows: 

** The diagnosis codes (ICD-9) are currently three to five digits that are alphanumeric in nature and combine to make around 14,000 unique diagnosis codes being used today. For ICD-10, the diagnosis codes will be seven digits that are alphanumeric in nature and combine to make around 68,000 unique diagnosis codes 

** Currently, ICD-9 procedure codes are three to four digits that are numeric in nature and  combine  to  make  about  4,000  unique  procedure  codes.    For  ICD-10-PC  S (inpatient), the procedure codes will be 7 alphanumeric in nature and combine to make around 72,000 unique procedure codes. 

3.  Q: What is the primary purpose of this change? 

A: The primary purpose of the change to ICD-10 is to improve clinical communication.  It allows for the capture of data about signs, symptoms, risk factors and comorbidities and better describes the clinical issues overall. It will also enable the United States to exchange information across country borders. 

4.  Q: What is CarePlus’ plan for ICD-10 acceptance? 

A:  CarePlus  will  accept  ICD-9  codes  on  claims  w/  date  of  service  (DOS),  or  discharge  dates  of September 30, 2014 or prior.  CarePlus will accept ICD-10 codes on claims w/ DOS, or discharge dates of October 1, 2014 or after. 

5.  Q: Do you plan to be ready to process ICD-10 codes submitted on claims forms by Oct 1, 2013? 

A: CarePlus will go live with the ICD-10 codes effective October 1, 2014. 

6.  Q: How long will support for both ICD-9 and ICD-10 coding be provided?

A:  CarePlus  will  process  correctly  coded  transactions  within  the  date  ranges  specified  in  the  answers above until the volume of ICD-9 submissions is diminished. 

7.  Q: When will CarePlus begin testing transactions? 

A: CarePlus will begin testing ICD-10 transactions in the second quarter of 2014. 

HIPAA 5010 Frequently Asked Questions and Answers

 Its may be little late but still useful.

1.  Q: What is 5010? 

A: HIPAA mandates certain transaction types for electronically submitted claims.  The current format is ANSI  (American  National  Standards  Institute)  X12  version  4010.    HIPAA  has  mandated  the  industry move to the next version, X12 5010, by January 1, 2012. 

Following are the ANSI X12 transactions used by the health care industry: 

** The  claims  transaction  known  as  837  contains  three  transaction  types:    837P  - Professional, 837I - Institutional and 837D - Dental 

** The remittance advice for the 837 (claim) is the 835 transaction 

** The claim status request and response are 276/277 

** The eligibility request and response are 270/271 

** Referrals and authorizations are transmitted by 278 

** Enrollment uses the 834 

** Premium payments are made with the 820 

** There are other transactions known as acknowledgements, which are used to confirm the receipt of the above transactions. These include the 997, 824 and the negative 277. 

2.  Q: Why is this change needed? 

A: The move to the 5010 format is needed to support the introduction of the new ICD-10 code set and other current and future needs of the industry.  

3.  Q: Is there anything changing besides the accommodation of the ICD-10 codes? 

A: There are a number of changes in versioning. This includes deletions of data previously reported on the 4010 and the introduction of the new data, which are newly available or required to be submitted in version  5010.  Working  with  your  practice  management  system  representative  will  facilitate  a  smooth transition to the 5010 version. 

4.  Q: What is CarePlus  doing to prepare for version 5010? 

A: CarePlus  is working closely with the clearinghouses and other trading partners to confirm readiness for the new format. CarePlus began testing the new format in the fourth quarter of 2010 and continues to test.  Be  on  the  lookout  for  information  from  clearinghouses  about  changes  in  the  processes  that  may impact your practice. 

5.  Q: How will providers register in order to conduct testing for 5010 transactions? 

A: CarePlus’ transition to version 5010A1 is transparent to providers submitting transactions through a clearinghouse.  Contact  your  clearinghouse  for  information  regarding  its  lead-time  for  transition  to v5010A1.  Remember  that  you  should  be  conducting  testing  with  your  clearinghouses  to  ensure compliance. 

TEN STEPS FOR ACCURATE ICD-9 CODING

To  code  accurately,  it  is  necessary  to  have  a  working  knowledge  of  medical  terminology  and  to understand the characteristics, terminology and conventions of ICD-9-CM.  Transforming descriptions of diseases, injuries, conditions and procedures into numerical designations (coding) is a complex activity and should not be undertaken without proper training. 

Originally,  coding  allowed  retrieval  of  medical  information  by  diagnoses  and  operations  for  medical research,  education  and  administration.    Coding  today  is  used  to  describe  the  medical  necessity  of  a procedure  and  facilitate  payment  of  health  services,  to  evaluate  utilization  patterns  and  to  study  the appropriateness of health care costs.  Coding provides the basis for epidemiological studies and research into the quality of health care.   Incorrect  or inaccurate coding  can lead  to  investigations of  fraud and abuse.  Therefore, coding must be performed correctly and consistently to produce meaningful statistics to aid in planning for the health needs of the nation. 

Follow the steps below to code correctly: 

1.  Identify  the  reason  for  the  visit.  (e.g.,  sign,  symptom,  diagnosis,  conditions  to  be  coded). Physicians describe patient’s condition using terminology that includes specific diagnoses, as well as symptoms, problems or reasons for the encounter.  If symptoms are present but a definitive diagnosis  has  not  yet  been  determined,  code  the  symptoms.  Do  not  code  conditions  that  are referred to as “rule-out”, “suspected”, “probable”, or “questionable”. 

2.  Always consult the Alphabetic Index, Volume 2, before turning to the Tabular List.  The most critical rule is to begin a code search in the index.  Never turn first to the Tabular List (Vol. 1), as this will lead to coding errors and less specificity in code assignments.  To prevent coding errors, use both the Alphabetic Index and the Tabular List when locating and assigning a code. 

3.  Locate the main entry term. The Alphabetic Index is arranged by condition.  Conditions may be express as nouns, adjectives and eponyms. 

4.  Read and interpret any notes listed with the main term.   

Notes are identified using the italicized type. 

5.  Review entries for modifiers. 

Nonessential modifiers are in parentheses. The parenthetical terms  are supplementary words or explanatory information that may either be present or absent in the diagnostic statement and do not effect code assignment. 

6.  Interpret abbreviations, cross-references, symbols and brackets.  

 Cross-references  used  are  “see”,  “see  category”,  or  “see  also.”    The  abbreviation  NEC  may follow main terms or sub-terms.  NEC may follow main terms or sub-terms.  NEC (not elsewhere classified)  indicates  that  there  is  no  specific  code  for  the  condition  even  though  the  medical documentation may be  very specific.  The check box indicates the code requires an  additional digit.  If the appropriate digits are not found in the index, in a box beneath the main term, you 

MUST refer to the Tabular List.  Italicized brackets [ ], are used to enclose a second code number that must be used with the code immediately preceding it and in that sequence. 

Hospice CPT Coding FAQ

How do I bill for hospice services? 

The following is an excerpt from the “Part B Answer Book” CD-ROM. 

Hospice Care: Overview 

If  one  of  your  patients  has  a  terminal  illness,  with  about  six  months  or  less  to  live,  your  patient  can  choose  either  standard  Medicare  coverage  or  hospice  care.  When  someone  chooses  hospice  benefits, he/she may continue to rely on a private doctor and at the same time make use of the hospice physician. 

As of Aug. 5, 1997, hospice care is available for two 90-day periods and an unlimited number of 60-day periods during the hospice patient’s lifetime. 

Hospice services (including those of the hospice physician) are billed under Part A to the intermediary, which pays 100% of Medicare’s approved charges. Services for an attending physician not connected to the hospice are billed to the carrier. Such services by an attending physician should be coded with the GV  modifier

What Medicare Will Pay For 

Medicare hospice benefits pay for treatment designed to keep  your patient as comfortable as possible. Attempts  to  cure  the  condition  that  brings  your  patient  to  the  hospice  don’t  fall  under  this  particular benefit. (The carrier’s medical staff makes the decision about what is and isn’t palliative care). However, you can bill Medicare for curative treatment that isn’t part of the terminal condition, just as you ordinarily would, whether you’re the patient’s private doctor or you work for the hospice. 

Once hospice coverage is elected, the patient isn’t eligible for Medicare Part B services related to the treatment and management of his terminal illness. One big exception is that professional services of an attending physician may be billed under Part B. To qualify as an attending physician, the patient must identify at the time he elects hospice coverage, the physician (doctor of medicine or osteopathy) who has the most significant role in his/her medical care. The attending physician doesn’t have to be employed by the hospice, and the patient still may be treated by hospice-employed physician. 

Two Paths for Reimbursement 

You can bill the carrier for treatment and management of a hospice patient’s terminal illness and get paid 80% of the Medicare fee schedule amount (plus the co-insurance and deductible) – as long as you are the attending physician, and you don’t furnish the services under a payment arrangement with the hospice. 

Member Enrolled in hospice ? Does Medicare HMO covers the service?

What is Hospice? 

Hospice is a program of care and support for people who are terminally ill.  It is available as a benefit under Medicare Hospital Insurance (Part A).  The focus of hospice is on care, not treatment or curing an illness.  Emphasis  is  placed  on  helping  people  who  are  terminally  ill  live  comfortably  by  providing comfort and relief from pain. Some important facts about hospice are: 

** A  specially  trained  team  of  professionals  and  caregivers  provide  care  for  the  “whole  person”, including his or her physical, emotional, social and spiritual needs. 

** Services may include physical care, counseling, drugs, equipment, and supplies for terminal illness and related condition(s). 

** Care is generally provided in the home. 

** Hospice isn’t only for people with cancer. 

** Family caregivers can get support. 

When all the requirements are met, the Medicare hospice benefit includes: 

** Physician and nursing services 

** Medical equipment and supplies 

** Outpatient drugs or biological for pain relief and symptom management 

** Hospice aide and homemaker services 

** Physical, occupational and speech-language pathology therapy services 

** Short term inpatient and respite care 

** Social worker services 

** Grief and loss counseling for the member and his or her family 

When  a  member/patient  enrolled  in  hospice  receives  care  from  your  practice  or  facility,  it  is  very important that all of the care be coordinated with their hospice physician. Once a Member is enrolled in hospice, CarePlus Health Plans, Inc. (CarePlus) is not financially responsible for any services covered by Medicare regardless of whether the care is related to the hospice diagnosis or not, as long as the service provided is a Medicare covered benefit. CarePlus enrolls Hospice members into a new group effective the 1st of the month, following election of hospice, and removes them from the group at the end of the month, if the Member terminates or revokes the hospice benefit.  The Plan will continue to assist in coordination of the member’s care to the best of its ability, however, the payment process to providers changes. 

What is MEDICATION THERAPY MANAGEMENT (MTM)

Purpose: 

** To optimize therapeutic outcomes for individual patients. 

** Optimize drug therapies. 

** Improve medication use. 

** Reduce risk of adverse events and drug interactions. 

** Increase patient adherence and compliance with prescription drugs. 

** Identify interventions that provide improved care to members. 

** Interventions should result in health benefits for the Members and cost effective for the Members  and CarePlus. 

Medicare Required Criteria for MTM Eligibility: 

** Beneficiary must have multiple chronic diseases. 

** Beneficiary must have filled multiple covered Part D drugs. 

** Beneficiary must be likely to incur annual cost of more than $3,000 all covered Part D drugs. 

CarePlus MTM Eligibility: 

** Member must be diagnosed with 3 or more core chronic disease conditions. 

** Members with 8 or more unique Part D Medications. 

** Have anticipated cost of medications above a predetermined dollar amount ($3,000 per year for 2012) (Ex. If a Member spends more than $1,000 in a quarter, it can be assumed they will spend  at least $3,000 in a year.) 

CMS STAR RATINGS

The  Centers  for  Medicare  &  Medicaid  Services  (CMS)  uses  a  five-star  rating  system  to  measure  Medicare beneficiaries’ experience with their health plans and the health care system. This rating system  applies  to  all  Medicare  Advantage  (MA)  lines  of  business:  Health  Maintenance  Organization  (HMO),  Preferred  Provider  Organization  (PPO),  Private  Fee-for-Service  (PFFS)  and  prescription  drug  plans  (PDP).  

The program is a key component in financing health care benefits for MA plan enrollees. In addition, the  ratings  are  posted  on  the  CMS  consumer  website,  www.medicare.gov,  to  give  beneficiaries  help  in  choosing among the MA plans offered in their area. 

CMS Goals for the Five-star Rating System 

* Implement provisions of the Affordable Care Act 

* Clarify program requirements 

* Strengthen beneficiary protections 

* Strengthen CMS’ ability to distinguish stronger health plans for participation in Medicare Parts C 

and D and to remove consistently poor performers 

How Are Star Ratings Derived? 

A health plan’s rating is based on measures in five categories:  

* Members’ compliance with preventive care and screening  recommendations 

* Chronic condition management 

* Plan responsiveness, access to care and overall quality  

* Customer service complaints and appeals 

* Clarity and accuracy of prescription drug information and pricing 

Benefits to Providers 

* Improved patient relations 

* Improved health plan relations 

* Increased awareness of patient safety issues 

* Greater focus on preventive medicine and early disease detection 

* Strong benefits to support chronic condition management 

claim submission guideline form SHP

Claims Submission

Claims are to be submitted to Simply Healthcare Plans with appropriate documentation by mail or filed electronically for CMS-1500 and UB-04 claims. For those members that may be assigned to a delegated medical group/IPA that does its own claims processing, please verify the “Remit To” address on the SHP Member ID Card. Providers billing SHP directly should submit claims to:

Simply Healthcare Plans, Inc.

Attn: Claims

PO BOX 21535

Eagan, MN 55121

Providers are expected to use good faith effort when billing SHP for services by using the most current coding (ICD-9, CPH, HCPCS, etc.) available. The following information is to be included on all claims submissions, electronic or paper:

3. Member’s name, date of birth, sex and ID number

4. Date(s) of service, place of service(s) and number of days or units, if applicable

5. Provider tax identification and NPI number

6. ICD-9 diagnosis codes by specific service to the highest level of specificity

7. Current CPT, revenue and HCPCS procedure code(s) with modifiers is appropriate

8. Billed charges per service(s) provided and total charges

9. Provider name and address, signature, and phone number

10. Information about other insurance coverage, Workers’ Compensation, accident or auto information, if available

11. Attach a detail description of the service or procedure for claim submitted with unlisted medical or surgical CPT or other revenue codes

12. For resubmissions and corrections of a claim, please submit a new CMS 1500 or UB-40 indicating the correction.

Submission of Formal Grievances and Appeals: to simply health care insurance

Providers are encouraged to first communicate any concerns or dissatisfaction about an SHP process or decision verbally through the Provider Relations telephone lines at 1-800-887-6888 ext. 6005 Monday through Friday between 8 AM and 7 PM EST, excluding state holidays. After hours, an electronic voice messaging system will record provider complaints.

1. All SHP providers have the right to submit a formal written appeal to SHP:

* within 45 calendar days from the denial disposition on a referral/authorizations/grievance

adverse determination;

* within 365 calendar days from the date of service for a claim adverse decision

2. A provider’s written grievance and/or appeal must be forwarded to the SHP Provider Appeals

Coordinator at the following address:

Simply Healthcare Plans, Inc.

1701 Ponce De Leon Blvd, Suite 300

Coral Gables, Fl 33134-4414

Toll Free Number: 1-800-213-1133

Attn: Provider Appeals Coordinator

3. Provider grievances and appeals are handled by the Provider Appeals Coordinator and are reviewed with the corresponding and designated department head.

4. All provider complaints are investigated using applicable statutory, regulatory, contractual and provider contract provisions, collecting all pertinent facts from all parties and applying the Plan’s written policies and procedures.

5. SHP’s Director of Provider Relations, and the Chief Operating Officer and/or Chief Medical  Officer if appropriate, are involved in the provider complaint process, and have authority to require corrective action plans.

6. Upon the receipt of the provider grievance/appeal letter, a provider grievance acknowledgement letter will be forwarded to the provider within five (5) working days from the receipt of the document.

7. A resolution to the provider’s appeal will be rendered and communicated to the provider in writing within a sixty (60)-day period from the receipt of the provider appeal or grievance. The letter will include information on filing a Level II appeal, should the provider not be satisfied with the decision.

8. Grievance extensions: If the review of the grievance (excluding appeals) involves the collection of

information outside the service area or from a non-participating provider, an additional 30 days extension is allowed, with prior notification to the provider.

9. The time limitations requiring completion of the grievance review shall be tolled after SHP has notified the provider in writing that additional information is required. Upon the receipt of the additional information required, the time frame for completion of the grievance process shall resume.

10. For appeals/grievances requiring a re-review of clinical records, a Medical Director or consultant other than the one who made the initial review will process the appeal and corresponding documents and render a determination.