Important update from PUP

ALL CMS PUP patient would be moved Medicare from June 1. We could submit the claim to Medicare and get paid See the below notice form PUP.

HIPAA - some important website resources

Look to the AMA and website resources for updates. 

The HIPAA Privacy, Security and Breach Notification rules continue to be revised, and technological change continues to impact the application of those rules. Physician practices must ensure they stay on top of these changes to protect their patients’ rights, maintain compliance and avoid the potentially draconian penalties for violations.

American Medical Association HIPAA information 

AMA provides a host of information designed to help physicians comply with the HIPAA Privacy,

Security and Breach Notification Rules. 

http://www.ama-assn.org/go/HIPAA

US Department of Health and Human Services (DHHS) Office of Civil Rights (OCR) 

The HHS OCR website contains a wealth of information on the HIPAA Privacy and Security Rules,

including a list serv and a link to the Transaction and Code Sets information posted by CMS.

http://www.hhs.gov/ocr/privacy/index.html

Centers for Medicare and Medicaid Services (CMS) 

This link to the CMS website includes information on the Transaction and Code Sets Rule.

http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Guidance.html 

HIPAA Understand the basics

HIPAA is the acronym for the Health Insurance Portability and Accountability Act. Although HIPAA covers many things, physicians typically are most concerned with HIPAA’s Administrative Simplification provisions, and particularly the Privacy, Security and Breach Notification requirements. Since it was originally enacted, HIPAA has been amended and expanded several times as a result of new laws and regulations. The most sweeping change resulted from the Health Information Technology for Economic and Clinical Health Act (HITECH), enacted as part of the American Recovery and Reinvestment Act of 2009 (ARRA).

This toolkit provides an overview of the HIPAA Privacy, Security and Breach Notification Rules with which almost all physicians must comply. At their core, these rules simply implement longstanding physician commitments to protect the confidentiality of their patients’ medical information and maintain open physician-patient communications. However, the specificity of the requirements goes well beyond traditional, self-evident obligations, and violations can result in serious penalties. Thus, physicians need to understand these rules and participate in a formal compliance plan designed to ensure all the requirements are met.   Physicians should also note that HIPAA is considered a “floor,” meaning, states may have requirements that go above and beyond what the federal government requires.  This toolkit is focused on the federal mandates.

In a nutshell, these three core compliance areas include:  

1.  The Privacy Rule 

The Privacy Rule restricts covered entities’ and business associates’ use and disclosure of an individual’s "protected health information" (PHI). Physicians who transmit PHI electronically in a HIPAA Standard Transaction, such as by filing electronic claims or checking eligibility electronically even if they are using a third party such as a billing service or a clearinghouse, are “covered entities,” and bound by HIPAA.  “Business associates” include those persons and companies that physicians hire to help their practice and that have access to their patients’ PHI, such as billing services, attorneys, accountants and consultants. "Protected health information" means individually identifiable information that is held or transmitted by a covered entity or business associate in any form or media—whether electronic, paper,or oral, that relates to the past, present, or future physical or mental health of an individual, health care services, or payment for health care. The Privacy Rule also provides for “individual rights” such as a patient’s right to access their PHI, restrict disclosures, request amendments or an accounting of disclosures and their right to complain without retaliation.

Medicare and Medicaid cross over claim - with different NPI

 If a claim is submitted to Medicare and 3 lines pay and 2 deny--will the two denied lines crossover on that claim? 

 If a provider bills multiple lines to Medicare and Medicare pays one or more lines but denies the others, the paid line(s) (as long as there are PRs) will be crossed over to Medicaid and the provider must resubmit the crossover payment as an adjustment to Medicaid to add the additional lines.

What if the deductible causes the claim to be zero paid by Medicare? 

The claim will still be crossed over and the deductible will be paid by Medicaid.

 Are Medicare Part C or Part D claims part of the crossover process? 

No, Part C and Part D claims will not be part of the crossover process.

 What will happen if I bill Medicare with a different NPI than I use to bill Medicaid? 

The NPI that is used on your Medicare claim must be enrolled with NY Medicaid.  Your crossover claims will not be processed if the NPI on your Medicare claim is not enrolled with NY Medicaid. In this case, Medicaid will reject the cross over claim back to Medicare and Medicare will send a notification letter of the rejection to the provider

How do I enroll my NPI with NY Medicaid to take advantage of payments of crossover deductibles and coinsurance? 

Enrollments application can be found on this website under Provider Enrollment. Questions about the enrollment process may be directed to the eMedNY Call Center at 1-800-343-9000.

Will Medicare cross over claims with no patient responsibilities? Clinic pricing, how much payment for crossed over claims?

 How does the Medicare Crossover process affect my Medicaid billing? 

You will no longer need to submit claims directly to Medicaid for those Medicaid patients who have both Medicare (Parts A &/or B) and Medicaid.

Will Medicare Crossover process affect my Medicare billing? 

In most instances, there are no changes to how you bill Medicare however Institutional providers who submit with rate codes are encouraged to include the Medicaid rate code on their claim to Medicare if they submit on the 837I . (See the next FAQ on how to  bill with a rate code)

 I receive enhanced Clinic pricing on my claims, will that payment methodology continue? 

The enhanced pricing will continue only if the claim submitted to Medicare contains your Medicaid rate code. If the claim submitted to Medicare does not have your Medicaid rate code the crossover payment will be only the deductible, coinsurance or co-pay due.  Send your claim to Medicare with the Medicaid rate code in Loop 2300 in the HI Value Information segment in data element HI01. 

(visit eMedNY.org for more information at www.emedny.org/hipaa/FAQs/Rate_Codes.html) Rate codes are sent to Medicaid as 4-digit (numeric) values. If submitting the rate code to Medicare, the following amount format should be used: (NN.NN). N=number and the decimal must be included.

If you do not send the Medicaid rate code on your claim to Medicare, you will need to resubmit an adjustment to Medicaid with the correct rate code on the claim in order to receive the enhanced Clinic payment.