Qualis Health. Quarterly

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1 Qualis Health Quarterly Nebraska Medicaid September 2011 Welcome to Qualis Health s quarterly newsletter for Nebraska Medicaid Services. We hope you will find the newsletter useful and informative, and we welcome your comments and feedback. Cindy Treffer, RN NE Program Manager Dale Michels, MD NE Medical Director Under the direction of the Nebraska Department of Health and Human Services, Qualis Health has helped ensure the efficiency, economy, effectiveness and quality of healthcare services provided to Nebraska Medicaid clients since November HOME HEALTH AUTHORIZATIONS Qualis Health receives requests for pre-authorization and continued care certifications from Nebraska Medicaid providers via our secure web-based portal iexchange. It is important to remember that the primary diagnosis code entered by a provider on an open case must not be changed. If a client has a change in diagnosis code, a new case must be entered into iexchange by the home health agency staff. Changing the diagnosis code on an open case results in a change to all prior certification periods. If your agency has yet to bill for a particular period of time and the diagnosis is changed after authorization by Qualis Health, your claim will likely be denied when you submit it for payment. If you have questions regarding the need to open a new case, change a diagnosis, etc., please contact our office at (402) We will be glad to assist you. CONTACT US: Qualis Health PO Box Lincoln, NE Phone: (402) Toll-free: (877) Fax: (877) Business Hours: Monday through Friday 8:00 am to 5:00 pm CST

2 HOME HEALTH CLIENTS WITH DUAL ELIGIBILITY FOR MEDICARE AND MEDICAID Many Nebraska Medicaid recipients have dual eligibility for Medicare and Medicaid, meaning they are eligible to receive benefits from both programs. The following information from Nebraska Department of Health and Human Services, Division of Medicaid and Long-term Care clarifies Nebraska s Medicaid coverage rules and regulations for dually eligible clients: 471 NAC Medicare Coverage: Medicare coverage is considered to be the primary source of payment for home health agency services for eligible individuals age 65 and older and for certain disabled beneficiaries. NMAP (Medicaid) does not make payment for services denied by Medicare for lack of medical necessity. NMAP (Medicaid) may cover services denied by Medicare for other reasons if the services are within the scope of NMAP (Medicaid). Claims submitted to the Department for services provided to Medicare-eligible clients must be accompanied by documentation which verifies that the services are not covered by Medicare. 471 NAC Third Party Resources (TPR): All third party resources available to a Medicaid client must be utilized for all or part of their medical costs before Medicaid. Third party resources (TPR) are any individual, entity or program that is or may be, contractually or legally liable to pay all or part of the cost of any medical services furnished to a client. Third party resources include, but are not limited to - 1. Private health insurance; 2. Casualty insurance, including medical payment provisions; 3. Employment-related group health insurance; 4. Group health plans defined under section 607(1) of ERISA; 5. Medicare Part A and/or Part B; 6. Medicare Part C (Medicare Advantage plans); 7. Medicare Part D; 8. Medical support from non-custodial parents (court or administrative ordered) (see 471 NAC ); 9. Excess income/share of cost (see 471 NAC ); 10. Workers compensation; 11. Other federal programs (unless excluded by statute, such as Indian Health Services programs and Migrant Health programs and Title V, Maternal Child Health Program); 12. Liable third parties who are not insurance carriers; 13. Medical payments provisions of automobile and commercial insurance policies; and 14. Any other party contractually or legally liable to pay medical expenses.

3 NURSING SERVICES PROVIDED IN SCHOOL SETTINGS With the start of the new school year, home health providers have asked questions regarding how to bill and whom to bill for nursing services being provided during a child s school day for medically necessary care. Nebraska Medicaid Rules and Regulations outline the following related to Medicaid reimbursement for these services: 471 NAC Payor of Last Resort: Medicaid clients who have third party resources must exhaust these resources before Medicaid considers payment for any services. Medicaid shall not pay for medical services as a primary payor if a third party resource is contractually or legally obligated to pay for the service. Providers shall bill all third party resources and/or the client (when there is an excess income/share of cost obligation) for services provided to the client, except for waiver claims (see 471 NAC A). Providers shall submit all charges and Medicare covered services provided to Medicare/Medicaid clients to Medicare plus any Medicare supplement plans for resolution prior to billing Medicaid. Medicaid is the payer of last resort. SEE ALSO: Title 92 NAC Chapter 51 ( Rule 51 ) Related services means transportation and such developmental, corrective and other supportive services as are required to assist a child with a disability to benefit from special education and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, early identification and assessment of disabilities in children, counseling services, including rehabilitation counseling, orientation and mobility services and medical services for diagnostic or evaluation purposes. Related services also include school health services and school nurse services, social work services in schools and parent counseling and training. Related services do not include a medical device that is surgically implanted (including cochlear implants), the optimization of that device s functioning (e.g., mapping), maintenance of that device or the replacement of that device. This definition does not limit the right of a child with a surgically planted device (e.g., cochlear implant) to receive related services as listed in this definition that are determined by the IEP team to be necessary for the child to receive FAPE or limits the responsibility of a district to appropriately monitor and maintain medical devices that are needed to maintain the health and safety of the child, including breathing, nutrition or operation of other bodily functions, while the child is transported to and from school or is at school; or prevents the routine checking of an external component of a surgically implanted device to make sure it is functioning properly.

4 REMINDERS FOR PRIVATE DUTY NURSES Nebraska Medicaid reminds private duty nurses of some important deadlines: 1 LPN PDNs must update their provider agreements before October 31, 2011 or be at risk for delay of payments. This coincides with LPN licensure renewal. 2 Both RNs and LPNs must obtain their national provider identification (NPI) numbers and begin using them along with the taxonomy and nine digit zip code (zip+ four) for ALL claims submitted for payment to NE DHHS on or after January 1, Failure to do this will cause a delay in payments. Questions should be directed to, toll free, (888) See Provider Bulletin 11-14, QUESTIONS ABOUT HOME HEALTH OR PDN CLAIMS? Home health agencies and private duty nurses are reminded to contact the NE DHHS inquiry line for questions regarding claims issues. The inquiry line toll-free number is: (877) Lincoln providers may call (402) ELIGIBILITY VERIFICATION All providers are asked to verify client Medicaid eligibility prior to providing service. Medicaid eligibility can be verified by calling the Nebraska Medicaid Eligibility System (NMES), toll-free, at (800) Lincoln providers may call (402) NMES can also provide information on a client s enrollment with a managed care plan. FLU SEASON APPROACHING.WHAT ABOUT FLU VACCINE FOR HOME HEALTH PATIENTS? NE DHHS will soon be releasing provider bulletins regarding flu vaccine administration for home health clients. Providers are encouraged to check the Department s website for updates and provider bulletins on a regular basis. Information is available at ne.gov/med/provhome.htm.

5 HOSPITAL RETROSPECTIVE REVIEW RECORDS Hospitals submitting medical records to Qualis Health are encouraged to submit the records on CD. We request one record per CD. Please bookmark each section. CD s should be labeled with the client s name, Medicaid ID number, hospital name dates of service, along with the medical record number and claim number. Hospitals utilizing outside copying agencies are encouraged to contact the agency regarding submitting your records on CD. Reminder: Qualis Health and Nebraska Medicaid do not reimburse the facility or the copying agent for the cost of medical records or for postage. If you have questions regarding submitting records on CD, please contact Qualis Health s Jennifer Stokes or Pam Bly at (402) QUALIS HEALTH TO PERFORM PRIOR AUTHORIZATION REVIEWS FOR BARIATRIC SURGICAL PROCEDURES Qualis Health will begin performing prior authorization reviews for bariatric surgical procedures on behalf of the Nebraska Department of Health and Human Services, Division of Medicaid and Long-term Care. We will be working with physician office staff to provide information and education about how to request a review, required information to submit and the Qualis Health review process. Education sessions will be conducted by webinar. Watch your for additional information. If you have questions or need immediate assistance regarding an authorization for a bariatric surgical procedure, please contact Qualis Health at (402)

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