Geisinger Gold Open A Private Fee-for-Service Plan Provider Guide and Terms and Conditions

Transcription

1 Geisinger Gold Open A Private Fee-for-Service Plan Provider Guide and Terms and Conditions Geisinger Gold Open Provider Manual 1

2 Table of Contents Plan Overview 3 Advantages of Gold Open 4 Who to call 4 Deeming Provider Information 5 Sample Identification Cards 7 Member Cost Sharing Information 8 Billing Information 11 EDI Enrollment Requirements 11 Reimbursement Methodology 13 Frequently Asked Questions 19 Geisinger Gold Open Provider Manual 2

3 Plan Overview Geisinger Gold Open is a Medicare Advantage (MA) Private Fee For Service (PFFS) plan offered by Geisinger Indemnity Insurance Company, an affiliate of Geisinger Health Plan. Gold Open is available to Medicare beneficiaries residing in the following Pennsylvania counties: Berks, Blair, Bradford, Cambria, Carbon, Centre, Clearfield, Clinton, Columbia, Cumberland, Dauphin, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northumberland, Perry, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wyoming and York. Geisinger Gold Reserve is a Medicare Advantage Medical Savings Account plan. Members of Gold Reserve can go to any doctor or hospital that accepts Medicare and the plans payment terms and conditions (just like Gold Open). Geisinger Gold Reserve is available in Berks, Centre, Clinton, Columbia, Dauphin, Lackawanna, Lancaster, Lebanon, Luzerne, Lycoming, Montour, Northumberland, Sullivan, Union, Wyoming and York counties. For more information on Gold Reserve, please call our Customer Service Team at (800) , Seven days a week from 8 a.m to 8 p.m. (TDD/TTY (800) ). Providers who provide services to a Gold Open member must be state licensed, have a Medicare billing number or be eligible to obtain one. Institutional providers such as hospitals or skilled nursing facilities must be Medicare-certified health care facilities. If a provider does not want to provide services to Gold Open members, the member must seek care from another Medicare participating provider who is willing to furnish services and is willing to accept our Terms and Conditions. From the Gold Open member's perspective, Gold Open offers the freedom to choose doctors and hospitals, the ability to see specialists without a referral and to travel within the United States without losing coverage. Members continue to pay the Medicare Part B premium and are responsible for the Gold Open premium and any cost sharing, such as copayments or coinsurance. Physicians, hospitals and other health care providers or suppliers do not sign an agreement with Geisinger Indemnity Insurance Company or Geisinger Health Plan. Providers are considered "deemed" a Gold Open approved provider when: 1. they know in advance of providing services to a Gold Open member that the member is enrolled in Gold Open, and 2. render services based on this knowledge, and 3. have reasonable access to the our Terms and Conditions. Federal health care providers, including the Veterans Administration, are not eligible for reimbursement from Gold Open except when providing emergency care. Please call Geisinger Gold Customer Service for more information at (800) , Seven days a week from 8 a.m to 8 p.m. (TDD/TTY (800) ). Geisinger Gold Open Provider Manual 3

4 Advantages of Gold Open This is a fee-for-service Medicare Advantage plan, not an HMO. Providers are reimbursed at rates equivalent to the Medicare allowable rates, less any member cost-sharing amounts for covered services. Please refer to the Terms and Conditions and member cost sharing list for more information. Physician, hospitals and other health care providers do not sign an agreement with Geisinger Health Plan or Geisinger Indemnity Insurance Company, but need to be licensed or certified by the state, acting within their scope of license or certification and not be sanctioned or have opted out of Medicare. Precertification, prior authorization and referrals are not required. Claims can be filed electronically. Gold Open adheres to federal prompt payment requirements and processes at least 95% of clean claims in 30 or fewer days. If for some reason a clean claim cannot be paid within 30 days, interest will be paid. Full coverage for Gold Open members while traveling throughout the United States. Gold Open is a local health plan Members have the choice of enrolling in Geisinger Gold's Medicare Prescription Drug plan. Free fitness center membership and health and wellness programs. Who to Call Our Gold Customer Service Team is available to members and providers to provide assistance with the following: eligibility verification, benefit questions, claim status or billing questions, as well as reconsiderations and appeal procedures. (800) or (570) , seven days a week from 8 a.m to 8 p.m. (TDD/TTY (800) Geisinger Gold Open Provider Manual 4

5 Deeming Provider Information Contact Information: Gold Customer Service Team (800) or (570) For more comprehensive information on Gold Open, please visit Physicians, hospitals and other healthcare providers or suppliers do not sign an agreement with Geisinger Indemnity Insurance Company or Geisinger Health Plan. Providers are considered a Gold Open deemed provider when the provider a) knows in advance of providing services, that the Member is enrolled in Gold Open and renders services based on this knowledge and b) has reasonable access to the Terms and Conditions. Federal healthcare providers, including the Veterans Administration, are not eligible for reimbursement from Gold Open, except when providing emergency care. Under the Plan s Terms and Conditions, a Gold Open deemed provider: Agrees to accept payment rates equivalent to the Medicare allowable rate less any member cost sharing amount for services rendered. For more information on calculation of reimbursement rates or current billing requirements, we encourage you to visit our Web site at Select Gold Open then Terms and Conditions for complete information. Gold Open adheres to Medicare s Prompt Payment requirements for all clean claims. Providers may not balance bill a Gold Open member if they accept Plan s Terms and Conditions. Must: Be licensed or certified by the state and be acting within the scope of that license or certification, and not be sanctioned or have opted out of Medicare. Obtain an individual or organizational NPI number from the NPI Registry maintained by Fox Systems. Applications may be obtained through Comply with Medicare and other federal health care program laws, regulations and program instructions that apply to the services furnished to enrollees. Issue the Notice of Medicare Non-Coverage (NOMNC) and Detailed Explanation of Non- Coverage (DENC) in accordance with Medicare guidelines. Notices can be accessed via the CMS Website at For additional information on these requirements, please go to the following Web page: Abide by the Gold Open appeal and grievance procedures, including hospitals, skilled nursing facilities, home health agencies or certified outpatient rehabilitation facilities providing appropriate written notices to Members in advance of service ending. Contact the Gold Customer Service Team at (800) for information about Gold Open member s appeal and grievance procedures. Follow the Plan s process for provider appeal under Geisinger Health Plan Gold Open if a provider has information that Original Medicare would reimburse more for a service. The provider appeal must be submitted in writing with a copy of the Explanation of Payment (EOP), an explanation of the appeal and, if applicable, additional related documentation, within 60 days of the date indicated on the EOP to: Gold Open, PO Box 8200, Danville, PA Provider appeals, received within 60 calendar days from the EOP date, will be reviewed and responded to in writing within 60 calendar days of their receipt. Agree to collect only the Gold Open member s cost sharing amounts or amounts for noncovered services; balance billing is not permitted. Gold Open is very similar to Original Geisinger Gold Open Provider Manual 5

6 Medicare. For a summary of Gold Open benefits and member cost sharing amounts please see the complete Terms and Conditions available on at Agree that in no event, including but not limited to, nonpayment by Gold Open, insolvency of Gold Open or breach of these Terms and Conditions, shall a provider bill, charge, collect a deposit from, seek compensation, remuneration or reimbursement from, or have any recourse against an enrollee or persons (other than Gold Open) acting on behalf of the Gold Open member for services provided pursuant to the Terms and Conditions. Agree to submit claims in accordance with CMS/plan s billing guidelines. For complete billing instructions including electronic process, visit You further agree that: 1) this provision supercedes any contrary oral or written agreement now existing or hereafter entered into between you and a member or persons acting on their behalf and 2) this provision shall apply to all of your employees, agents, trustees, assignees and subcontractors, and you shall obtain from such persons specific agreement to this provision. This provision does not prohibit providers from collecting charges for noncovered services or applicable cost sharing amounts. Agree that if the Terms and Conditions are not accepted, provider may not provide services to a Gold Open member, except in an urgent or emergent situation. Geisinger Gold Open Provider Manual 6

7 Sample Identification Card For 2008, PCP, SCP and ER copays will display on the front of the ID card. The benefit code has been moved to the back. Gold Reserve cards will not display copay information. All services are applied to deductible. Geisinger Gold Open Provider Manual 7

8 Gold Open Member Cost Sharing Information Copayments for applicable services can be collected at the time of service. Providers may find it beneficial to allow the plan time to adjudicate the claim before attempting to collect the coinsurance amount. The exact cost-sharing amount will be printed on the Explanation of Payment returned to the provider, once claim adjudication has occurred. Benefits are in accordance with Medicare s coverage criteria. Geisinger Gold Open Provider Manual 8

9 Geisinger Gold Open Provider Manual 9

10 Geisinger Gold Reserve Cost Sharing Information Geisinger Gold Open Provider Manual 10

11 Billing Information All claims for Geisinger Gold Open members must be filed according to the timely filing deadlines mandated by Medicare. Timely filing limits according to Medicare guidelines as follows: For services furnished between January and September, the provider has until December 31 of the following year to submit the claim to Geisinger Gold. For services furnished October through December, the claim must be received by December 31 of the second following year. For example: Date of Service : File Claim By: January 1, 2008 December 1, 2009 October 1, 2008 December 1, 2010 Contact the Gold Customer Service Department at (800) or (570) , seven days a week from 8 a.m to 8 p.m. EST with questions related to the claim submission process. Claim submission requirements for Geisinger Gold Open are consistent with CMS claim submission requirements. To access the CMS billing guidelines, providers can go to Claims are reimbursed according to Medicare s payment methodologies in effect on the date of service for covered services. For additional billing information, providers are encouraged to utilize their Medicare manuals for assistance. All applicable data elements, including NPI numbers and current coding conventions, are required for all services reported, such as the then current CPT and/or HCPCS Level II procedure codes, revenue codes, ICD-9-CM diagnosis coding to the highest level of specificity, as applicable to the diagnosis. Providers are required to report their appropriate NPI numbers or their appropriate Medicare number on every claim, as well as the Gold Open member s identification number. Hard Copy Claim Submission Hard copy claims should be submitted to the following: Geisinger Gold Open P.O. Box 8200 Danville, PA Providers are required to utilize either a CMS 1500 or UB92 hard copy claim form when reporting health care services. Electronic Claim Submission Prior to initiating electronic claim transactions, our Electronic Data Interchange (EDI) Enrollment Form must be fully processed. The EDI Enrollment Form is available in PDF on our Web site at Geisinger Gold Open Provider Manual 11

12 Submit the completed EDI Enrollment Form electronically, by fax or US mail to: Geisinger Health Plan PNM Operations/EDI Enrollment North Academy Avenue Danville, PA Fax: (570) When the EDI Enrollment Form has been fully processed, we will release a written notification to the EDI enrollee communicating necessary start-up information. Geisinger Health Plan is contracted with Emdeon Corporation, who receives and sends electronic transactions on our behalf. For further information regarding Emdeon Corporation, please contact them directly at (800) or visit their Web site at EDI formatting specifications are delineated in our Companion Documents, which are available in PDF on our Web site at We strongly encourage EDI enrollees to ensure that their claim submission software vendor/billing company has taken all necessary steps to confirm all required data elements are captured and populating in accordance with applicable Companion Documents. EDI Clearinghouse Reports Understanding and using clearinghouse reports is crucial for maintaining and managing electronic claims. These reports contain concise information regarding the status of electronic claims, identifying those that are have been accepted and those that need to be resubmitted. A claim reported electronically is not considered received by Geisinger Gold Open until it has been accepted into its claim processing system. To monitor the status of electronic claims transmitted to us, the following Emdeon reports should be reviewed regularly: Emdeon Initial Rejection/Provider Daily Statistics Report, R022: This report contains totals of claims submitted, accepted and rejected, by batch, listing detailed error explanations. Rejected claims appearing on this report are not forwarded to Geisinger Gold Open and should be corrected and resubmitted to Emdeon as soon as possible. Emdeon Initial Accept/Daily Acceptance Report by Provider Report, R026: This report lists the claims accepted by Emdeon that have been forwarded on to Geisinger Gold Open. These claims passed clearinghouse edits, but may be rejected by Geisinger Gold Open upon its editing procedures. To monitor the status of claims appearing on this report resulting from our editing procedures, you should also review the Emdeon Payer Reject/Unprocessed Claims Report R059. Emdeon Payer Reject/Unprocessed Claims Report R059: This report identifies claims that cannot be processed by Geisinger Gold Open, and lists the corrective action that should be taken. Claims appearing on this report are not accepted and should be corrected and resubmitted as soon as possible. Geisinger Gold Open Provider Manual 12

13 Reimbursement Methodology SERVICE CATEGORY Acute Care Hospital-Inpatient Services Acute Care Hospital-Inpatient Outliers Acute Care Hospital-Outpatient Services Ambulance Ambulatory Surgery Center Anesthesia/Physician Performed Anesthesia-Physician Medical Direction of 2 or more Nurse Anesthetists concurrently Assistant surgeon (physician assistant) Assistant surgeon (physician) Blood Braces Cancer Hospitals-Inpatient Cancer Hospitals-Outpatient PAYMENT METHODOLOGY PPS Reimbursement (DRGs). Includes capital, DSH, capital IME, and special payment adjustments to MDHs and SCHs when applicable. Operating IME and DME do not have to be paid by Medicare Advantage plans to acute care PPS hospitals since the Fiscal Intermediary will make these payments. Pass-through payments for capital, CRNAs, and costs associated with nursing and allied health education programs if applicable. Organ acquisitions reimbursed on a cost basis at an approved transplant facility. Payment is 80% of the excess of the cost of an admission over the sum of the DRG payment (including IME and DSH) and a threshold amount. The threshold amount in 2005 is $25, HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. This software calculates the outlier payments and passthrough payments. Blended method between reasonable charge for ambulance supplier and national fee schedule.cy 2005 the blend is 80% of the national fee schedule and 20% of the reasonable charge. ASC fee schedule According to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units According to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units 50% of the allowance for the service performed by the physician 85% x 16% of the amount paid to a physician who serves as an assistant at surgery. 16% of the amount applicable for global surgery under the Medicare fee schedule. Reimbursed under OPPS for hospital outpatient services 100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic and Supplies Fee Schedule. Covered when furnished incident to physicians' services or on a physicians' order Contact facility for their pricing information. If unable to obtain, pay claim at 50% of billed charges. If payment incorrect, facility can submit copy of Medicare RA showing correct pricing. We will adjust claim to reflect correct pricing. HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. Geisinger Gold Open Provider Manual 13

14 Certified Registered Nurse Anesthetist (CRNA) Children's Hospitals-Inpatient Children's Hospitals-Outpatient Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Clinical Trial Services Community Mental Health Centers CORF Co-Surgeons Critical Access Hospitals Diabetic Shoes Drugs Durable Medical Equipment Epoetin (EPO) ESRD Facility Federally Qualified Health Centers According to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units Payment is made on an assignment basis only. The above allowance is divided equally between the anesthesiologist and the anesthetist (50% each) Contact facility for their pricing information. If unable to obtain, pay claim at 50% of billed charges. If payment incorrect, facility can submit copy of Medicare RA showing correct pricing. We will adjust claim to reflect correct pricing. HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. 85% MFS 100% MFS-pyschologists will receive payment for administering diagnostic psychological tests and supervising the administration of these tests 75% MFS Medicare directly reimburses all approved clinical trial services provided to an M+C enrollee according to the appropriate fee for service methodology HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. Reimbursement based on the Medicare physician fee schedule. Vaccines reimbursed 95% AWP. The fee schedule amount applicable to the payment for each cosurgeon is 62.5% of the global surgery under the Medicare fee schedule Paid at 101% of reasonable cost basis. Facility will be contacted for copy of their most recent interim rate letter from their Medicare fiscal intermediary. 100% Prosthetic/Orthotic fee schedule Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. 100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. ESRD facilities are paid, for routine services, a composite rate. Composite rates are geographically adjusted. They also vary depending on whether a facility is hospital based or independent. Non-routine services are paid based on fee schedule. Paid 80% of the lower of the all inclusive rate or the upper limit; plus 20% of the FQHC's actual charge FQHC limit: $ Rural FQHC limit: $97.13 Geisinger Gold Open Provider Manual 14

15 Hemophilia clotting factors billed by provider (e.g. Hosp, SNF, HHA) Hemophilia clotting factors billed by supplier (e.g. DME, supplier, indep pharmancy, Red Cross) Home Dialysis Supplies & Equipment Home Health Home Infusion Hospital Transfer Acute to Acute Hospital Transfer Acute to Postacute HPSA (Health Prof Shortage Area) Immunosuppressive Drugs, transplant Indian Health Service Facility (HIS)-inpatient services Indian Health Service Facility (HIS)-outpatient services Injections Add on payment for beneficiaries in an inpatient setting. Outpatient setting paid on a cost basis. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. Method I or II per Medicare PPS (HHRGs) Providers reimbursed per 60 day episode via RAP and claim submission. Includes adjustments for LUPA, SCIC, PEP, therapies and outliers. Limited services reimbursed under OPPS. DME reimbursed at 100% DMEPOS fee schedule. Note: Effective 4/1/04 rural agencies will be paid a 5% add-on payment. Reimbursement per Medicare Durable Medical Equipment Prosthetic, Orthotic and Supplies Fee schedule for applicable services. The first hospital is paid a per diem rate equal to the DRG amount divided by the average length of stay for that DRG. A maximum of the full DRG is paid to the first hospital. The second hospital is paid the full DRG. Expanded Transfer Definition: A qualified discharge from one of the 29 DRGs to a postacute care provider will be treated as a transfer case and reimbursed the per diem methodology stated above, with the following exception. DRGs 209,210 and 211 are paid under a methodology where 50% of the DRG plus the per diem is paid on the first day of the stay. For each subsequent day, 50% of the per diem is paid up to the full DRG amount 100% of the MFS + 10% bonus Paid under OPPS if beneficiary is in the outpatient dept of a Medicare participating hospital. In all other settings, 85% average wholesale price. HSS "Winstrat" DRG Grouper/Pricer software. Winstrat contains a National Medicare Provider Rate File (NMPRF) which provides Gold Open with the capability to Group/Price DRG claims for ANY medicare approved provider. All-inclusive rate. Excluded from OPPS. Fee schedule for outpatient professional services. Physicians can also be paid for injections and vaccinations even when performed on the same day as other Medicare covered services. Laboratory Long Term Care Hospitals 100% of Medicare laboratory fee schedule LTCH PPS (DRGs) effective for cost reporting periods beginning on or after 10/01/02. Payment subject to a five year blend in 20% increments unless LTCH elects to be paid based on 100% Federal PPS rate. Short stay and high cost outliers apply. Low Volume Hospitals This is a new payment under MPDMA. If a hospital has under 800 discharges per year, and is more than 25 miles from the closest acute care hospital, CMS makes an additional payment not to exceed 25%. This new payment is to be effective on 10/1/04. Mammography Screening 100% MFS Geisinger Gold Open Provider Manual 15

16 Maryland Hospitals Medical Nutrition Therapy Nurse Practitioner Oral Anti-Cancer Drugs Oral Anti-Nausea Parenteral and Enteral Nutrition Physical, Occupational, Speech Therapist Physician Assistant Physician Scarcity Area (PSA) Physician Services (Audiologist) Physician Services (Chiropractor) Physician Services (Dentist) Physician Services (DO) Physician Services (MD) Physician Services (Optometrist) Physician Services (Oral and Maxilofacial Surgeon) Physician Services (Podiatrist) Prosthetic Devices Psychiatric Hospitals-Inpatient HSCRC mandated rate thresholds. Reimbursed 94% of approved charges for IP and OP services. 85% of the Medicare fee schedule. 85% MFS Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. PEN fee schedule 100% MFS 85% MFS 100% MFS + 5% bonus 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 5% PSA payment where appropriate. 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 5% PSA payment where appropriate. 100% Medicare Fee Schedule. 10% HPSA payment where appropriate. 5% PSA payment where appropriate 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 5% PSA payment where appropriate. 100% of the Medicare physician fee schedule. 10% HPSA payment where appropriate. 100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic and Supplies Fee Schedule. For hospital fiscal years beginning after 1/1/05, the payments will be a blend of 75% of the old TEFRA payment and 25% of the new PPS payment. The first PPS payment period for all hospitals will extend to 6/30/06, after which all PPS updates will be for the 12 month periods beginning 7/1. The second payment period uses a blend of 50% TEFRA / 50% PPS, and the third and last transition year uses 25% TEFRA / 75% PPS. There is a "stop/loss" adjustment which sets the PPS payment to no less than 70% of the TEFRA amount for this 3 year transition period.the new PPS system uses a federal per diem base amount of $ which is then adjusted for one of 15 DRG's, comorbidities, age, rural add-on, teaching add-on, outlier payments, wage index, the presence of an emergency department, and ECT treatment. There is also an extra payment which tapers down during the first 21 days of an admission. Geisinger Gold Open Provider Manual 16

17 Psychiatric Hospitals-Outpatient HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. Registered Dietitican 85% MFS Rehab Hospital-Inpatient Services Utilize pricer via CMS website Rehab Hospital-Outpatient Services HSS "Winstrat" APC Grouper/Pricer software. Winstrat contains an Outpatient National Medicare Provider Rate File (ONMPRF) which provides Gold Open with the capability to Group/Price APC claims for ANY medicare approved provider. Religious Non-Medical Health Care Institutions Rural Health Clinics Skilled Nursing Facilities Sole Community Hospital Surgical Dressings Contact facility for their pricing information. If unable to obtain, pay claim at 50% of billed charges. If payment incorrect, facility can submit copy of Medicare RA showing correct pricing. We will adjust claim to reflect correct pricing. Paid 80% of the lower of the provider specific rate or the per visit payment limit; plus 20% of the RHC's actual charges per visit limit: $72.76 Note: Per visit limits do not apply to RHCs owned by rural hospitals with less than 50 beds and are paid on a cost basis. PPS reimbursement (RUGS) Paid the greater of PPS or the hospital specific rate for a full year. PRICER calculates the greater of the 2. The Medicare DMEPOS fee schedule applies to all surgical dressings except those applied incident to a physician's professional services, those furnished by an HHA and those applied while a patient is being treated in an outpatient hospital department or as an acute care inpatient.hospital outpatient reimbursed under PPS (APCs) HHA'spayment is bundled into PPS (HHRGs). If a physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner. Swing Beds TOPS (Transitional outpatient payments) SNF PPS (RUGS) CAH swing beds are exempt from SNF PPS and are paid on a reasonable cost basis. Tops payments are made to hospitals paid less under PPS than under the old cost system. Rural hospitals with 100 beds or less that are not sole community hospitals (SCH s) will continue to receive payments until 12/31/08 Transfers between Acute Care Hospitals The first hospital is paid a per diem rate equal to the DRG amount divided by the average length of stay for that DRG. A maximum of the full DRG is paid to the first hospital. The second hospital is paid the full DRG. Geisinger Gold Open Provider Manual 17

18 VA Hospitals X-Ray Federal providers are excluded from participation in the Medicare program. However, Federal Hospitals, like other non participating hospitals may be paid for emergency inpatient and outpatient hospital services.hospital filed claims: Inpatient: Lower of actual charges or rates published for Federal Hospitals in the Federal Register under OFFICE OF MANAGEMENT & BUDGET-Cost of Hospital & Medical Care & Treatment. Outpatient: 85% of the total covered charges. 100% of the Medicare physician fee schedule Geisinger Gold Open Provider Manual 18

19 Frequently Asked Questions General Questions 1. What is a deemed provider? A deemed provider is a physician or other health care provider who knows in advance of providing services that the member is enrolled in Gold Open and renders services based on this knowledge and has reasonable access to our Terms and Conditions. If a physician or health care provider renders care to a Gold Open member, the physician or health care provider is considered deemed to have a contract or deemed for that member. Physicians and other health care providers must be licensed and must be eligible to provide care to Medicare-eligible patients with no sanctions against their licensure. For a copy of our full Terms and Conditions, please visit our Web site, thehealthplan.com, or contact our Customer Service Team at Does the physician have a responsibility to notify the plan that he or she is deemed? No. There are no contracts to sign, and there is no paperwork required to participate. As with any insurance plan, the physician or other health care provider should ask to see the member s ID card to identify the individual as a Gold Open member. If the provider renders care to the member, that provider is deemed. You may choose to provide care to Gold Open members on a patient-by-patient basis and may stop treating Gold Open members at any time. 3. What is the reimbursement for a deemed provider? Deemed providers are reimbursed the Medicare allowed amount from the Medicare fee schedule. If a physician or other health care provider did not know the member was a Gold Open member and submitted a claim as unassigned, that provider is considered nondeemed. Gold Open pays the non-deemed physician or other health care provider the Medicare limiting charge, minus the CMS-approved Gold Open member s cost-sharing amount. Once Gold Open has paid a physician or other health care provider, that provider has met the deeming requirements for that enrollee and will be considered deemed for all future care of that member. A physician or other health care provider will only be paid once as a non-deemed provider for a Gold Open member. Non-deemed providers may not balance bill the patient. 4. Which fee schedule does Gold Open use to determine the physician payment rate? As with Original Medicare, the fee schedule for the locality where the service is rendered is used to reimburse physicians and other health care professionals. Please review the reimbursement methodolgy section of this manual for more information. 5. What services are subject to the annual deductible? Gold Open members do not have inpatient or outpatient deductibles. Gold Reserve members have an annual $3,000 deductible. Geisinger Gold Open Provider Manual 19

20 6. What happens in an emergency? Physicians and other health care providers who render care in an emergency are not considered deemed by default because a claim was submitted to Gold Open. In accordance with 42 CRF (f), Gold Open will not assume that the services provided by a hospital, physician or other health care provider in an emergency department are provided by deemed providers. Gold Open will process the claims as filed (accepting Medicare or not accepting Medicare assignment) and will pay the accepting provider the Medicare allowable, minus the Gold Open member s cost-sharing amount. Gold Open will pay the non-accepting Medicare health care provider the Medicare limiting charge, minus the Gold Open member s cost-sharing amount. 7. What Local Medical Review Policies (LMRPs) do you use? We use the same LMRPs as Original Medicare. Gold Open uses the LMRPs in effect for the area where care is rendered. 8. Are Medicare ID numbers or provider NPI numbers required on claims submitted to Geisinger Gold Open? Yes. The health care provider s tax ID and Medicare ID or UPIN number are required to price and process the claims appropriately. In addition, facilities should use sub-unit identifiers with their facility ID when submitting claims. 9. What happens if a member disenrolls from Gold Open and goes back to Original Medicare? How are the member s cost-shares calculated? If a member disenrolls from Gold Open and returns to Original Medicare, then Original Medicare cost-sharing provisions apply. 10. What format does Gold Open require for claims? Use the same format as you use for Original Medicare. Geisinger Gold Open accepts paper or electronic claims. If your office currently submits claims electronically to Geisinger Health Plan, you can continue to submit Gold Open claims using the same process. However, paper claims should be submitted to: Geisinger Gold Open P.O. Box 8200 Danville, PA Do additional documentation requirements (ADR) apply to this plan? The same ADR requirements apply as they do for Original Medicare. 12. Are there contracted participating providers, which are required to be used? Geisinger Gold Open Provider Manual 20

21 No. There are no contracted participating providers under this plan. The member can have services performed at any Medicare-approved provider that is willing to accept the Gold Open Terms and Conditions. 13. Does Gold Open require Advanced Beneficiary Notices (ABN) for services, which are not covered under Medicare? No. You must inform the member in advance that a specific service will not be covered. The notice may be verbal or in writing, however, you are encouraged to document the discussion. 14. What is the claims payment timeliness standard for Gold Open? As a Medicare Advantage Organization (MAO) under contract with the Centers for Medicare & Medicaid Services (CMS), Gold Open must follow the Medicare Advantage rules. These contain provider protections, including prompt payment to health care providers. Under this provision, a MAO must pay 95 percent of clean claims within 30 days of receipt for services rendered under deemed or written contracts. The MAO must pay interest on all claims that are not paid within 30 days. All other claims must be approved or denied within 60 days of the request. 15. How does a physician or health care provider verify their claims status or a Gold Open member's eligibility? Providers should call Customer Service at (800) , seven days a week from 8 a.m to 8 p.m. 16. What if a provider does not want to accept the Gold Open plan? A physician or other health care professional may decide on a patient-by-patient basis to accept Gold Open. If the provider chooses not to be deemed and not to accept the payment Terms and Conditions that provider must not provide services to the Gold Open member. 17. If a member has services rendered by both deemed and non-deemed physicians or health care providers, how are member cost-sharing amounts handled? The Gold Open member s cost-sharing amounts are not affected by the deemed status of the physician or other health care provider. The member is responsibility only for the copayments or coinsurance as stated in their Subscription Certificate. Facility Provider Questions 1. How are payments for outpatient hospital services determined? Reimbursement is determined by Ambulatory Payment Classification (APC) codes. However, under Original Medicare, the APC code payment methodology often includes a high beneficiary cost-share; this is not the case under Gold Open. For Gold Open members, Gold Open pays the full Medicare-allowed amount, minus the member s Gold Geisinger Gold Open Provider Manual 21

22 Open cost-sharing amount. Outpatient copayments/coinsurance are based on the type of facility where care is rendered. 2. How does inpatient reimbursement work? Reimbursed is determined by the full Diagnostic Related Group (DRG) allowable amount, minus the Gold Open member s cost-share amount for inpatient services. Teaching hospitals receive an extra payment from Medicare. 3. Does Gold Open pay the teaching hospital this extra payment as well? No. The Centers for Medicare & Medicaid Services (CMS) carved out operating Indirect Medical Education (IME), Direct Graduate Medical Education (DGME), nursing and allied health from the Medicare Advantage contractors. Medicare pays these add-ons directly through its fiscal intermediaries. 4. Should hospitals include the Gold Open case experience in their cost reports? Yes. According to CMS, hospitals should include their Private Fee-For-Service (PFFS) cases in their cost reports. 5. Under Original Medicare, hospital patients must fill out a Medicare Secondary Payer (MSP) questionnaire. Should hospitals implement this process for Gold Open members? Yes. Hospitals should have their patients fill out the MSP. Gold Open reimburses physicians or other health care providers and attempts to recover the money from any third party that might be liable after the fact. 6. Under Original Medicare, hospitals submit cost reports to Medicare on a yearly basis. Adjustments to payments are made if necessary. Is this process implemented under the Gold Open plan? No. The previous year s cost reports are the basis for determining the payment rates. Gold Open will not make year-end settlements. 7. If a Gold Open member transfers from an acute inpatient facility to an acute rehabilitation facility, is the member responsible for another admission copayment? No, as long as the member is transferred. If the member is discharged to the acute rehabilitation facility, this is considered a separate admission and the inpatient copayment would apply. 8. In inpatient situations, how would a physician(s) know if the beneficiary is enrolled in the Gold Open plan? Physicians and other health care providers must know the type of health plan the patient has in order to bill for their services. They must know a patient s plan enrollment if they billed Gold Open. Therefore, if the physician or other health care provider renders Geisinger Gold Open Provider Manual 22

23 services to a Gold Open member, Gold Open will reimburse the provider as a "deemed provider." Home Health/DME Provider Questions 1. What eligibility criteria are required for home health care services? Gold Open uses the same home health criteria as Original Medicare. Contact Customer Service at (800) , Seven days a week from 8 a.m to 8 p.m. (TDD/TTY (800) ) with your questions. 2. Are payments the same as the Medicare Prospective Payment System (PSS)? Yes, Gold Open uses the Original Medicare PPS as the payment fee schedule for home health services. 3. Is there an initial and final payment, as with Original Medicare, or is there one payment per 60-day episode? Gold Open pays the same way as Original Medicare with an initial and final payment. However, home health agencies may request reimbursement per 60-day episode of care by submitting a request for accelerated payment (RAP). 4. Is reimbursement from Home Health Resource Group (HHRG) codes for a 60-day episode of care? Yes, the same as Original Medicare. 5. What is the copayment for infusion care provided in a home health care setting? Some plans have cost sharing for home health services. There is member coinsurance for DME related to home health services, including the infusion pump. As with Original Medicare, most Medicare-covered drugs for home health are included in the home health PPS rate. Please refer to the cost sharing charts in this document. Questions About Terms & Conditions 1. When are PFFS plans allowed to change their terms and conditions? Gold Open Terms and Conditions will not change more frequently than annually with the exception of changes made in payment rates and methodologies directed by CMS under Original Medicare or mid-year benefit enhancements to the member s cost-sharing amount. Any changes are posted on our Web site at Reimbursement rates are tied to Medicare fee schedules and only change if Medicare rates change. Under Gold Open Terms and Conditions, we continue to pay at least the Medicare reimbursement rate. 2. Where are changes posted and how are physicians or other health care providers notified? Geisinger Gold Open Provider Manual 23

24 Any changes to the Terms and Condition are posted on our Web site, You can also get information on our Terms and Conditions by contacting our Customer Service Team at (800) , Seven days a week from 8 a.m to 8 p.m. (TDD/TTY (800) ). Gold Open provides information by telephone, mail, or fax, as requested. Our goal is to send an annual notice to providers. 3. Is it the responsibility of the physician/health care provider to check the terms and conditions? While Gold Open does not anticipate frequent or significant changes to the Terms and Conditions, it is the physician s or other health care provider s responsibility to understand the Terms and Conditions. The physician or health care provider should check the Terms and Conditions as frequently as necessary. Prescription Drug Coverage Questions 1. Are Gold Open members eligible for Medicare prescription drug coverage? Yes. Geisinger Health Plan offers Medicare prescription drug coverage to all Gold Open members. Members who elect this coverage will have an identification card separate from their medical coverage identification card. 2. What medications are covered? For a copy of our formulary, please visit our Web site at and select providers followed by formulary search." HPM50 Geisinger Gold Open Provider Manual Dev.10/05 Rev.6/06 Rev.5/07 Rev. 12/07 Geisinger Gold Open Provider Manual 24