West Virginia Reimbursement Policies Table of Contents

Transcription

1 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Administration Claims Requiring Additional Documentation 4 Claims Submission - Required Information for Facilities 7 Claims Submission - Required Information for Professional Providers 10 Claims Timely Filing: Participating and Nonparticipating 13 Code and Clinical Editing Guidelines 15 Documentation Standards for Episodes of Care 18 Duplicate or Subsequent Services on Same Date of Service 21 Eligible Charges 24 Emergency Services: Nonparticipating Providers and Facilities 26 Inpatient Facility Transfers 29 Inpatient Readmissions 31 Locum Tenens Physicians 33 Other Provider Preventable Conditions 35 Present on Admission Indicator for Health Care-Acquired Conditions 37 Requirements for Documentation of Proof of Timely Filing 40 Reimbursements for Items under Warranty 43 Reimbursements of Claims with Charge Discrepancies 45 Reimbursement of Sanctioned and Opt-Out Providers 47 Scope of Practice 49 Site of Service Payment Differential - Professionals 51 Anesthesia Professional Anesthesia Services 53 Coding West Virginia Reimbursement Policies Table of Contents Assistant at Surgery (Modifiers 80/81/82/AS) 57 Diagnoses Used in DRG Computation 59 Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU) 61 UniCare Health Plan of West Virginia, Inc. July

2 Modifier 22: Increased Procedural Services 64 Modifier 24: Unrelated Evaluation and Management Services by the Same Physician 66 Modifier 25: Significant, Separately Identifiable Evaluation and Management Service 68 Modifier 57: Decision for Surgery 70 Modifier 62: Co-Surgeons 75 Modifier 63: Procedures Performed on Infants less 4kg 77 Modifier 66: Surgical Teams 80 Modifier 76: Repeat Procedure by the Same Physician 83 Modifier 77: Repeat Procedure by Another Physician 85 Modifier 78: Unplanned Return to the Operating/Procedure Room 88 Modifier 91: Repeat Clinical Diagnostic Laboratory Test 91 Modifier LT and RT: Left Side/Right Side Procedures 93 Modifier Usage 95 Multiple Bilateral Surgery: Professional and Facility Reimbursement 98 Reimbursement for Reduced and Discontinued Services 101 Reimbursement of Services with Obsolete Codes 104 Robotic Assisted Surgery 106 Split-Care Surgical Modifiers 108 Unlisted or Misc. Codes (aka Dump Codes) 111 Drugs Drug and Injectable Limits 113 Facility Take-Home Drugs 115 Evaluation and Management Consultations 117 Physician Standby Services 122 Preventive Medicine and Sick Visits on the Same Day 124 Facilities Preadmission Services for Inpatient Stays 126 Prevention Early and Periodic Screening, Diagnostic Treatment 129

3 Vaccines for Children Program 131 Prosthetics & Orthotic Prosthetic and Orthotic Devices 135 Radiology Portable/Mobile/Handheld Radiology Services 138 Surgery Abortion 141 Global Surgical Package for Professional Providers 143 Hysterectomy 147 Maternity Services 150 Sterilization 152 Transportation Transportation Services: Ambulance and Nonemergent Transport 155

4 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Claims Requiring Additional Documentation Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Professional providers and facilities are required to submit additional documentation for adjudication of applicable types of claims. If the required documentation is not submitted, the claim may be denied. Applicable types of claims include: Upon request, claims for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS), and home health and rehabilitation therapies (e.g., physical, occupational, speech) UniCare Health Plan of West Virginia, Inc. WEB-UWV

5 Reimbursement Policy: Claims Requiring Additional Documentation Page 5 of 160 Claims with unlisted or miscellaneous codes Claims for services requiring clinical review (e.g., complicated or unusual procedures, emergency room services, etc.) Claims for services found to possibly conflict with covered benefits to covered persons after validity review of member s medical records (e.g., member eligibility) Claims for services found to possibly conflict with medical necessity of covered benefits to covered persons (e.g., new technology, potential experimental or investigational procedures, devices, potential cosmetic procedures, etc.) Claims requesting an extension of benefits Claims being reviewed for potential fraud, abuse or demonstrated patterns of billing/coding inconsistent with peer benchmarks Claims for services that require an invoice (e.g., custom DME/ prosthetics that are reimbursed based on purchase price) Claims for services that require an itemized bill (e.g., stop-loss, denied inpatient days, carve-out services) Claims for beneficiaries with other health insurance Claims requiring documentation of the receipt of an informed consent form (e.g., sterilization,) Claims requiring a certificate of medical necessity (e.g., motorized wheelchairs, lymphedema pumps, oxygen, etc.) Appealed claims where supporting documentation may be necessary for determination of payment Other documentation required by the CMS and state or federal regulation UniCare may request additional documentation or notify the provider or facility of additional documentation required for claims, subject to contractual obligations. If documentation is not provided following the request or notification, UniCare may: Deny the claim, as provider failed to provide required prepayment documentation. Recoup monies previously paid on the claim if the provider failed to provide required documentation for postpayment review. UniCare is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation. History UniCare review approved and effective 03/01/15

6 Reimbursement Policy: Claims Requiring Additional Documentation Page 6 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Claims timely filing Documentation standards for episodes of care Unlisted or miscellaneous codes (aka: dump codes) Related materials None

7 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Claims Submission Required Information for Facilities Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Institutional providers (facilities) are required, unless otherwise stipulated in their contract, to submit the original CMS 1500/UB92 uniform institutional provider bill to UniCare for payment of health care services. Providers must submit a properly completed UB-04/CMS-1450 for services performed or items/devices provided. If the required information is not provided, the claim is not considered a clean claim and UniCare can delay or deny payment without being liable for interest or penalties. The UB-04/CMS-1450 claim form must include the following information, if UniCare Health Plan of West Virginia, Inc. WEB-UWV

8 Reimbursement Policy: Claims Submission Required Information for Facilities Page 8 of 160 applicable: Facility information (i.e., name and address) Bill type Federal tax ID number (TIN) Date period the UB-04/CMS-1450 covers Patient information (i.e., name, subscriber number, address, date of birth, gender and marital status) Admission date and type Admission hour for inpatient services only Point of origin for admission or visit Discharge hour for inpatient services only Patient discharge status code Condition code(s) Accident state, if applicable Occurrence code(s) and date(s) Occurrence span code(s) and date(s) Revenue code(s) and description(s) and applicable corresponding CPT/HCPCS codes, if necessary. Applicable claims billed only with the revenue code will be denied. Providers will be asked to resubmit with the correct CPT/HCPCS code in conjunction with the applicable revenue code Date(s), unit(s) and total charge(s) of service(s) rendered Insurance payer s information (i.e., name, provider number and coordination of benefits secondary and tertiary payer information) Prior payments payers, if applicable Insured s information (i.e., name, relationship to patient, member ID number, insurance group name and number, date of birth, employer name and location) Principal, admitting and other ICD-9 diagnosis codes, including 4th and 5th digit when required Present on admission (POA) indicator, as applicable Code (ICD-9 procedure) and date of principal procedure for inpatient services, if applicable National provider identifier state Medicaid provider number (in accordance with the applicable state requirements) Encounter reporting data elements in accordance with applicable state

9 Reimbursement Policy: Claims Submission Required Information for Facilities Page 9 of 160 compliance requirements, including: o Admission source code o Applicable value code for billed admission type code o Birth weight with applicable value and admission type codes o Facility type code o National drug code(s) (NDC) to include the NDC number, unit price, quantity and composite measure per drug UniCare cannot accept claims with alterations to billing information (e.g., using correction fluid/tape, crossing out or writing over mistakes). Claims that have been altered will be returned to the provider with an explanation of the reason for the return. Although UniCare prefers the submission of claims electronically through the electronic data interchange, UniCare will accept paper claims. A paper claim must be submitted on an original claim form with dropout red ink, computer-printed or typed, in a large, dark font in order to be read by optical character reading technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Acceptance of altered claim forms Claims requiring additional documentation Claims submission Required information for professional providers Other provider preventable conditions (OPPC) Present on admission indicator for health-care acquired conditions Related materials UniCare electronic data interchange manual

10 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care UniCare Health Plan of West Virginia, Inc. WEB-UWV Reimbursement Policy Subject: Claims Submission Required Information for Professional Providers Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy Professional providers of health care services are required, unless otherwise stipulated in their contract, to submit an original CMS-1500 health insurance claim form to UniCare for payment of health care services. Providers must submit a properly completed CMS-1500 for services performed or items/devices provided. If the required information is not submitted, the claim is not considered a clean claim, and UniCare will deny payment without being liable for interest or penalties. The CMS-1500 claim form must include the following information, if

11 Reimbursement Policy: Claims Submission Required Information for Professional Providers Page 11 of 160 applicable: Patient information (i.e., name, address, date of birth, gender, relationship to insured, medical condition as related to employment or an accident, marital status, employment and student status) Insured s information (i.e., member ID number, subscriber number, name, address including ZIP code, telephone number, policy group or FECA number, date of birth, name of employer or school, name of insurance plan or program and name of other health benefit plan) Coordination of benefits/other insured s information (i.e., name, date of birth, policy or group number, name of employer or school and name of insurance plan or program) Name of referring physician or source Indication of outside laboratory ICD-9 diagnosis code(s), including 4th and 5th digit when required Clinical Laboratory Improvement Act certification number Date(s) of service(s) rendered Place of service/location code(s) Description of services rendered using CPT-4 codes/hcpcs codes and appropriate modifiers Charge(s) for service(s) rendered Day(s) or unit(s) related to service(s) rendered Total charges, amount paid by patient (i.e., copay), and balance due Federal tax ID number Name and address of facility where services were rendered and the NPI of the service facility, if applicable National provider identifier: o Individual servicing provider s NPI must be reported as the rendering provider ID, if applicable o When billing is from a group, the group s NPI must be reported as the billing provider, if applicable Remittance information (i.e., name, address, telephone) Indication of signature on file or a handwritten or computer generated signature for the provider of service or his/her representative and date the form was signed National drug code(s) (NDC) to include the NDC number, unit price, quantity and composite measure per drug State Medicaid provider number as required by state regulation (in

12 Reimbursement Policy: Claims Submission Required Information for Professional Providers Page 12 of 160 accordance with the applicable state requirements) UniCare cannot accept claims with alterations to billing information (e.g., using correction fluid/tape, crossing out or writing over mistakes). Altered claims will be returned to the provider with an explanation of the reason for the return. Although UniCare prefers the submission of claims electronically through the electronic data interchange, UniCare will accept paper claims. A paper claim must be submitted on an original claim form with drop out red ink, computer-printed or typed, in a large, dark font in order to be read by optical character reading technology. All claims must be legible. If any field on the claim is illegible, the claim will be rejected or denied. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Acceptance of altered claim forms Claims requiring additional documentation Claims submission Required information for facilities Modifier usage Other provider preventable conditions Related materials UniCare electronic data interchange manual

13 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Claims Timely Filing: Participating and Nonparticipating Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of claims for covered services for covered members in compliance with federal and/or state mandates regarding claims timely filing requirements. UniCare follows the standard of 12 months for participating and nonparticipating providers and facilities. Timely filing is determined by subtracting the date of service from the date UniCare receives the claim and comparing the number of days to the applicable federal or state mandate. If there is no applicable federal UniCare Health Plan of West Virginia, Inc. WEB-UWV

14 Reimbursement Policy: Claims Timely Filing: Participating and Nonparticipating Page 14 of 160 or state mandate, then the number of days is compared to the company standard. If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last day of service. Limits are based on calendar days unless otherwise specified. If the member has other health insurance that is primary, then timely filing is counted from the date of the explanation of payment (EOP) of the other carrier. Providers resubmitting paper claims for corrections must clearly mark the claim Corrected Claim. Corrected claims submitted electronically must have the applicable frequency code. Failure to mark the claim appropriately may result in denial of the claim as a duplicate. Corrected claims must be received within the applicable timely filing requirements of the originally submitted claim due to the original claim not being considered a clean claim. Claims filed beyond federal or state-mandated, or UniCare standard timely filing limits will be denied as outside the timely filing limit. Services denied for failure to meet timely filing requirements are not subject to reimbursement unless the provider presents documentation proving a clean claim was filed within the applicable filing limit. UniCare reserves the right to waive timely filing requirements on a temporary basis following documented natural disasters or under applicable state guidance. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies Eligible charges Requirements for documentation of proof of timely filing Related materials None

15 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Code and Clinical Editing Guidelines Reimbursement Policy Effective Date: TBD Committee Approval Obtained: TBD Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare applies code and clinical editing guidelines (CCEG) to evaluate claims for accuracy and adherence to nationally accepted industry standards and plan benefits unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. UniCare uses software products that ensure compliance with standard code edits and rules. These products increase consistency of payment for providers by ensuring correct coding and billing practices are followed. CCEG consists of the following measures, including but not limited to: UniCare Health Plan of West Virginia, Inc. WEB-UWV

16 Reimbursement Policy: Code and Clinical Editing Guidelines Page 16 of 160 Code editing software, CMS National Correct Coding Initiative edits and outpatient code edits Clinical criteria Licensed clinical medical review Claims processing platform Per state requirements, UniCare publishes its use of specific commercial code editing software. UniCare only customizes applicable CCEG measures due to compelling business reasons. CCEG measures are updated as applicable and as needed to incorporate new codes, code definition changes and edit rule changes. All claims submitted after the configuration implementation date, regardless of service date, will be processed according to up-to-date CCEG measures. No retrospective payment changes, adjustments, and/or requests for refunds will be made when processing changes are a result of new code editing rules within a module update. The member is not responsible and should not be balance billed for any procedures for which payment has been denied or reduced as the result of CCEG measures. UniCare uses CCEG to analyze outpatient services, including those that are considered: Rebundled or unbundled services Mutually exclusive services Incidental procedures or items Inappropriately billed visits Diagnosis to procedure mismatch Upcoded services Other procedures and categories that are reviewed include: Cosmetic procedures Obsolete or unlisted procedures Age/gender mismatch procedures Investigational or experimental procedures Procedure eligibility (e.g., assistant at surgery, co-surgeons, surgical teams, multiple fee reductions, etc.) Procedures billed with inappropriate modifiers UniCare does not allow reimbursement for services, procedures, items, etc., that conflict with CCEG. History UniCare review approved and effective TBD

17 Reimbursement Policy: Code and Clinical Editing Guidelines Page 17 of 160 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Definitions General Reimbursement Policy Definitions Related policies None Related materials None

18 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Subject: Documentation Standards for Episodes of Care Reimbursement Policy Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member's benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare requires that upon request for clinical documentation to support claims payment for services, the provided information should: Identify the member Be legible Reflect all aspects of care To be considered complete, documentation for episodes of care will UniCare Health Plan of West Virginia, Inc. WEB-UWV

19 Reimbursement Policy: Documentation Standards for Episodes of Care Page 19 of 160 include, at a minimum, the following elements: Patient identifying information Consent forms Health history, including applicable drug allergies Physical examinations Diagnoses and treatment plans for individual episodes of care Physician orders Face-to-face evaluations, when applicable Progress notes Referrals, when applicable Consultation reports, when applicable Laboratory reports, when applicable Imaging reports (including X-ray), when applicable Surgical reports, when applicable Admission and discharge dates and instructions, when applicable Preventive services provided or offered, appropriate to member s age and health status Evidence of coordination of care between primary and specialty physicians, when applicable Working diagnoses consistent with findings and test results Treatment plans consistent with diagnoses Providers should refer to standard data elements to be included for specific episodes of care as established by The Joint Commission, formerly the Joint Commission on Accreditation of Healthcare Organizations. A single episode of care refers to continuous care or a series of intervals of brief separations from care to a member by a provider or facility for the same specific medical problem or condition. Documentation for all episodes of care must meet the following criteria: Legible to someone other than the writer Information identifying the member must be included on each page in the medical record Each entry in the medical record must be dated and include author identification, which may be a handwritten signature, unique electronic identifier or initials

20 Reimbursement Policy: Documentation Standards for Episodes of Care Page 20 of 160 Other documentation not directly related to the member Other documentation not directly related to the member, but relevant to support clinical practice, may be used to support documentation regarding episodes of care, including: Policies, procedures and protocols Critical incident/occupational health and safety reports Statistical and research data Clinical assessments Published reports/data UniCare may request that providers submit additional documentation, including medical records or other documentation not directly related to the member, to support claims submitted by the provider. If documentation is not provided following the request or notification, or if documentation does not support the services billed for the episode of care, UniCare may: Deny the claim Recover and/or recoup monies previously paid on the claim UniCare is not liable for interest or penalties when payment is denied or recouped because the provider fails to submit required or requested documentation. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract The Joint Commission standards Definitions General Reimbursement Policy Definitions Related policies Claims requiring additional documentation Claims submission Required information for facilities Claims submission Required information for professional providers Related materials None

21 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Duplicate or Subsequent Services on the Same Date of Service Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of a duplicate or subsequent service provided on the same date of service if billed with an appropriate modifier or with additional units, as applicable within benefit limits unless otherwise noted by provider, state, federal or CMS contracts and/or requirements. Reimbursement of a duplicate or subsequent service Reimbursement of duplicate or subsequent services is based on the correct usage of the modifiers below that indicate the service was UniCare Health Plan of West Virginia, Inc. WEB-UWV

22 Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service Page 22 of 160 appropriately repeated or additionally billed for the same member: Modifier 62: Co-surgeons Modifier 66: Surgical teams Modifier 76: Repeat procedure by the same physician Modifier 77: Repeat procedure by another physician Modifier 80: Assistant at surgery providing full assistance to the primary surgeon Modifier 81: Assistant at surgery providing minimal assistance to the primary surgeon Modifier 82: Assistant at surgery, when a qualified resident surgeon is not available to assist the primary surgeon Modifier AS: Assistant at surgery who is a nonphysician (e.g., physician assistant, nurse practitioner) Modifier 91: Repeat clinical diagnostic laboratory test Modifier GG: Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day Modifier GH: Diagnostic mammogram converted from screening mammogram on same day UniCare may deny a duplicate or subsequent service provided on the same date of service billed on the same or separate claims unless billed with an appropriate modifier. UniCare will review claims billed with suspected duplicate or subsequent services. Claims will be denied for services determined to be duplicate or subsequent claims without the appropriate modifier. Reimbursement of bundled services When a service is unbundled from a more complex or comprehensive service and billed individually on the same date of service as the more comprehensive service: The claim line for the individual service will be denied through code editing if billed on the same claim. The claim will be reviewed if billed on separate claims. The following modifiers indicate an individual service is distinct and separate from the more comprehensive service: Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 59: Distinct procedural service

23 Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service Page 23 of 160 History UniCare review approved and effective 03/01/15 References and research materials Definitions Related policies This policy has been developed through consideration of the following: CMS State Medicaid State contract Duplicate Services: A service is considered a definite duplicate if some or all of the following elements on the claim match: o Member o Date of service o Charge amount o Provider of service o Type of service, based on procedure or revenue codes used A service is suspected duplicate if the following elements on the claim match: o Member o Procedure code o Date of service Subsequent Service: For purposes of this policy, it is a medically necessary service that is performed or provided for the same member more than once on the same date of service General Reimbursement Policy Definitions Assistant at surgery (Modifiers 80/81/82/AS) Code and clinical editing guidelines Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Modifier 59: Distinct procedural service Modifier 62: Co-surgeons Modifier 66: Surgical teams Modifier 76: Repeat procedure by the same physician Modifier 77: Repeat procedure by another physician Modifier 91: Repeat clinical diagnostic laboratory test Modifier usage Related materials None

24 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Eligible Charges Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement of eligible charges unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Eligible charges are those charges billed by the provider subject to conditions and requirements which make the service eligible for reimbursement. Eligibility for reimbursement of the service is dependent upon application of the following conditions and requirements: UniCare Health Plan of West Virginia, Inc. WEB-UWV

25 Reimbursement Policy: Eligible Charges Page 25 of 160 Member program eligibility Provider program eligibility Benefit coverage Authorization requirements Provider manual guidelines UniCare administrative policies UniCare clinical policies UniCare reimbursement policies Code editing logic The allowed amount reimbursed for the eligible charge is based on the applicable fee schedule or contracted/negotiated rate after application of coinsurance, copayments, deductibles and coordination of benefits. UniCare will not reimburse providers for: Items the provider receives free of charge. Items the provider provides to the member free of charge. In the absence of clear language or specific reference to eligible charges in provider contracts, the use of the following terms will default to eligible charges as stated within this policy: Billed charges Covered charges Billed charges for covered services Allowed charges Percent of charge History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract National Association of Insurance Commissioners (NAIC) Model Regulation, 2013 Definitions General Reimbursement Policy Definitions Related policies Claims submission Required information for professional providers Related materials None

26 UniCare Health Plan of West Virginia, Inc. Medicaid Managed Care Reimbursement Policy Subject: Emergency Services: Nonparticipating Providers and Facilities Effective Date: 03/01/15 Committee Approval Obtained: 03/01/15 Section: Administration ***** The most current version of our reimbursement policies can be found on our provider website. If you are using a printed version of this policy, please verify the information by going to ***** These policies serve as a guide to assist you in accurate claims submissions and to outline the basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service is covered by a member s UniCare benefit plan. The determination that a service, procedure, item, etc., is covered under a member s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis, as well as to the member s state of residence. You must follow proper billing and submission guidelines. You are required to use industry-standard, compliant codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities. If appropriate coding/billing guidelines or current reimbursement policies are not followed, UniCare may: Reject or deny the claim Recover and/or recoup claim payment UniCare reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider, state, federal or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, UniCare strives to minimize these variations. UniCare reserves the right to review and revise our policies periodically when necessary. When there is an update, we will publish the most current policy to this site. Policy UniCare allows reimbursement for emergency services provided by nonparticipating providers and facilities unless provider, state, federal or CMS contracts and/or requirements indicate otherwise. Unless otherwise required by federal and/or state regulation or contract, reimbursement is based on no more than: Medicaid product lines only: The amount that would have been reimbursed to the provider by the beneficiary s state fee-for-service Medicaid program UniCare Health Plan of West Virginia, Inc. WEB-UWV

27 Reimbursement Policy: Emergency Services: Nonparticipating Providers and Facilities Page 27 of 160 All other product lines: The applicable out-of-network emergency rate for nonparticipating providers and facilities UniCare adheres to the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) and the Federal Medicaid Managed Care Regulations. UniCare will act in accordance with the Deficit Reduction Act (DRA) of 2005, Section 6085, with an effective date of January 1, 2007, that states: Any provider of emergency services that does not have in effect a contract with a Medicaid managed care entity that establishes payment amounts for services furnished to a beneficiary enrolled in the entity s Medicaid managed care plan must accept as payment in full no more than the amounts (less any payments for indirect costs of medical education and direct costs of graduate medical education) that it could collect if the beneficiary received medical assistance under this title other than through enrollment in such an entity. In a State where rates paid to hospitals under the State plan are negotiated by contract and not publicly released, the payment amount applicable under this subparagraph shall be the average contract rate that would apply under the State plan for general acute care hospitals or the average contract rate that would apply under such plan for tertiary hospitals. UniCare shall develop and maintain a record, pursuant to DRA stipulations, for West Virginia s payment methodology according to its FFS Medicaid program. DRA applicability will apply to the Medicaid product line. UniCare will not limit consideration of reimbursement for emergency services on the basis of lists of diagnoses or symptoms; however, additional medical record documentation may be required in order to clearly identify and determine appropriate reimbursement of emergency services. Claims for emergency services are subject to UniCare s eligible charges, code and clinical editing and claims requiring additional documentation policies. History UniCare review approved and effective 03/01/15 References and research materials This policy has been developed through consideration of the following: CMS State Medicaid State contract Deficit Reduction Act of 2005 (Pub.L. No ) Emergency Medical Treatment and Labor Act (EMTALA)