UNDER REVISION: REFER TO 7 AAC AAC 160 UNTIL REVISION IS COMPLETE. Hospice Care. Alaska Medical Assistance Program. Provider Billing Manual

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1 Alaska Medical Assistance Program Hospice Care Provider Billing Manual Prepared by

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3 Dear Medical Assistance Provider: We are pleased to provide you with the enclosed provider billing manual to help you prepare your Medical Assistance claim forms. This billing manual has been prepared by First Health Services Corporation for the State of Alaska. First Health Services is the fiscal agent for the Alaska Department of Health and Social Services. The manual contains basic information on coverage and billing for medical services you provide to qualified recipients of our various medical assistance programs. It is designed to help you: 1) fill out health insurance claim forms for your eligible patients, 2) understand what medical services are reimbursable, and 3) understand the policies and procedures of these programs. As policies and procedures change, you will receive the updated information through bulletins and replacement pages to this manual. Your manual has been arranged in a loose-leaf format divided by sections and numbered so that replacement pages can be easily inserted. It is important to review and insert the updated information promptly to keep a current reference. Claim forms with outdated information may cause the automated payment system to reject the claim request. It is extremely important that you and your claims personnel follow the instructions described in the manual for your claims to be processed quickly and efficiently. It is our intention to make this manual useful to you, and we welcome any suggestions about the format that you believe would be helpful. Sincerely, Dwayne B. Peeples Director

4 Alaska Medical Assistance Program Provider Billing Manual How To Use This Manual Information about how to bill the Alaska Medical Assistance program for reimbursement of services rendered to medical assistance recipients is contained in this provider billing manual. Provider billing manuals are specific to type of service (for example, there are separate manuals for inpatient hospital, physician services, pharmacy, chiropractic, etc.). Manual pages are printed on threehole paper and mailed to providers in a loose leaf format to make updating easy. The manuals are organized in three numbered sections to assist you in finding the information you need. Section I contains specific information about how to bill Medical Assistance for a particular type of service. Section II contains information about supplemental documents and instructions. Section III contains general Medical Assistance program information. Appendices are included at the end of the manual for additional information. A Table of Contents is included beginning on page vii of each provider billing manual. Use the Table of Contents to help locate information in your manual. Updated 09/02 Written Correspondence and Provider Training The provider billing manuals are meant to be used in conjunction with other provider communication, including Remittance Advice (RA) Messages, letters and other written correspondence, and information delivered at provider training seminars. Providers are notified of changes in billing and reimbursement policy in weekly RA Messages. An RA is issued weekly to providers with claims activity. The Message Page of the RA will contain important provider billing information (including new information, clarifications and reminders). Revised manual pages are mailed to providers after the RA Messages are issued. Provider training topics, dates and locations are also announced in the RA Messages. For information, questions or suggestions about the provider billing manuals, other correspondence, or provider training, contact First Health Services Corporation or the Division of Health Care Services at the phone numbers or addresses listed on pages v and vi. Updated 08/03 iv

5 First Health Services Corporation Telephone Inquiries Questions? Please call First Health Services Corporation at (907) or our in-state toll free number, , about your participation in Alaska Medical Assistance. The First Health Services staff has been fully trained to answer most of your questions immediately. The following numbers can help you with other, more specific, questions: Billing Procedures (8:00 a.m. 5:00 p.m.) in-state toll free (907) Claims & Eligibility Status (8:00 a.m. 5:00 p.m./claims) in-state toll free (8:00 a.m. 5:00 p.m./eligibility) (907) Electronic Data Interchange (EDI) Electronic Commerce Customer Support (ECCS) Coordinator in-state toll free (907) (907) Eligibility Verification System (EVS) (24-hour access) toll free Enrollment (8:00 a.m. 5:00 p.m.) in-state toll free (907) Fax for Provider Inquiry (PI) (907) or (907) for Prior Authorization (PA) (907) for EDI Attachments (907) or (907) for Resubmission Turnaround Documents (907) or (907) Prior Authorization (PA) (8:00 a.m. 5:00 p.m.) in-state toll free (907) Provider Inquiry/Provider Services (8:00 a.m. 5:00 p.m.) in-state toll free (907) Report Fraud, Waste, Abuse, or Misuse of the Medicaid Program by Providers or Recipients (24-hour access) toll free Internet First Health Services Corporation Alaska Updated 04/04 v

6 Addresses Adjustment/Voids First Health Services Corporation P.O. Box Anchorage, AK Appeals: Claims: 1st Level 2nd Level Hospital, ESRD, and LTC (IHS) Indian Health Services Pharmacy All Others First Health Services Corporation Appeals P.O. Box Anchorage, AK Division of Health Care Services Claims Appeal Section 4501 Business Park Boulevard, Suite 24 Anchorage, AK First Health Services Corporation P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK P.O. Box Anchorage, AK Electronic Media Claims (EMC)/Electronic Commerce Customer Support (ECCS) Enrollment Inquiries and Correspondence Prior Authorization SURS (Surveillance and Utilization Review Subsystem) First Health Services Corporation EMC Department/ECCS Department P.O. Box Anchorage, AK First Health Services Corporation Provider Enrollment P.O. Box Anchorage, AK First Health Services Corporation Provider Services Unit P.O. Box Anchorage, AK First Health Services Corporation Prior Authorization Unit P.O. Box Anchorage, AK First Health Services Corporation Surveillance and Utilization Review P.O. Box Anchorage, AK Updated 04/04 vi

7 State of Alaska Alaska Department of Health and Social Services * Internet Web Site: Call: (907) Alaska Medical Assistance/Division of Health Care Services Internet Web Site: Call: (907) Medicaid Provider Fraud Control Unit, Department of Law To report fraud of the Medicaid program by providers Call: (907) Write: Medicaid Provider Fraud Control Unit State of Alaska, Department of Law Criminal Division 310 K Street, Suite 300 Anchorage, AK Fraud Control Unit, Division of Public Assistance, Department of Health and Social Services To report recipient Fraud and Abuse of Medicaid and other public assistance programs Call: Write: Toll free: In Anchorage (907) In Wasilla (907) In Kenai (907) In Fairbanks (907) Fraud Control Unit State of Alaska, DHSS Division of Public Assistance 3601 C Street, Suite 200 Anchorage, AK Updated 08/04 * For more contact information, see Appendix A. vii

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9 Table of Contents Hospice Care Introductory Letter... iii How To Use This Manual... iv Telephone Inquiries... v Addresses... vi Section I Hospice Care Policies and Claims Billing Procedures I-1 Services...I-1 Table I-1. Hospice Care Services...I-2 Services Consistent with the Written Plan of Care...I-2 Nursing Care...I-2 Medical Social Services...I-2 Hospice Physician Services...I-2 Physical Therapy, Occupational Therapy, and Speech Therapy...I-2 Durable Medical Equipment, Medical Supplies, Biologicals, and Drugs...I-3 Home Health Aide and Homemaker Services...I-3 Counseling Services...I-3 Services in a Nursing Facility or Intermediate Care Facility for the Mentally Retarded...I-4 Private Duty Nursing Services...I-4 EPSDT on File for Recipients Under 21...I-4 Medicare/Medical Assistance Hospice Election...I-4 Documentation...I-5 Certification of Terminal Illness...I-5 Election Statement...I-5 Written Plan of Care...I-6 Prescribed Drugs: Prior Authorizations and Limitations...I-7 Provider Participation Requirements...I-7 Recipient Eligibility...I-8 Verification...I-8 Table I-2. Advantages of EVS...I-8 Eligibility Codes...I-8 Table I-3. Eligibility Codes for Hospice Services...I-8 Reimbursement...I-10 General...I-10 Pricing Methodology...I-10 Payment if a Recipient Resides in a Nursing Facility...I-10 Payments to a Hospice for Private Duty Nursing Services...I-10 Payments to a Hospice for Inpatient Care...I-11 Physician Services...I-11 Revenue Codes...I-12 TPL (Third Party Liability)...I-13 Federal TPL Waiver...I-13 Recipients with VA, Medicare, and Medicaid...I-13 Hospice ix

10 Obtaining a VA Medicaid Denial Letter...I-14 Providers Can Attach Other Insurance Benefit Booklet Pages...I-15 Third Party Liability (TPL) Avoidance...I-15 Claims Billing Procedures...I-18 Claims: General Instructions...I-18 Claims: Specific Instructions...I-18 Revenue Codes...I-18 UB-92 Instructions...I-18 Medicare/Medical Assistance Crossover Billing...I-26 Billing Medical Assistance for Services Denied or Limited by Medicare...I-26 Receiving Payment from Medical Assistance...I-26 Completing the Medicare/Medical Assistance Crossover Billing...I-27 Section II Supplemental Documents and Instructions Attachments to the Claim Form... II-1 Proof of Timely Filing Documentation... II-1 Electronic Claims Attachment Transmittal... II-1 Insurance Explanation of Benefits (EOB)... II-3 Explanation of Medicare Benefits/Medicare Remittance Notice (EOMB/MRN) or Medicare Payment Report... II-4 Transportation Authorization and Invoice (AK-04)... II-5 Requesting Transportation/Accommodation Services... II-5 Step By Step... II-6 Remittance Advice... II-10 Cover Page... II-10 Message Page... II-11 Adjudicated Claims (Paid and Denied Claims)... II-12 Adjustment Claims... II-14 Voided Claims... II-17 In-Process Claims... II-18 Financial Transactions... II-19 EOB Description Page... II-21 Remittance Summary... II-22 Resubmission Turnaround Document (RTD)... II-25 Adjustment/Void Request Form (AK-05)... II-30 General Guidelines... II-30 Adjustment... II-30 Void... II-30 Overpayment/Refund... II-31 Completing the Adjustment/Void Request Form (AK-05)... II-31 Claim Inquiry Form (AK-11)... II-34 General Guidelines... II-34 Completing the Claim Inquiry Form (AK-11)... II-34 Forms Order Request... II-36 Section III Alaska Medical Assistance Program General Program Information Program Introduction...III-1 Program Background...III-1 Program Objectives...III-1 Program Fiscal Agent...III-1 II-1 III-1 x Hospice

11 Table III-1. Guidelines to Efficient Telephone Inquiries...III-2 Provider Billing Information...III-2 Claims Processing Overview...III-2 HCPCS Coding...III-2 Unlisted Codes...III-3 Diagnosis Codes...III-3 Coding Updates...III-4 Claims Submission...III-4 Table III-2. Advantages of EDI Transactions...III-4 Computer Operations...III-4 Adjudication...III-4 Payment...III-5 Services...III-5 Medical Assistance Covered Services...III-5 Chronic and Acute Medical Assistance (CAMA) Covered Services...III-6 Denali KidCare...III-6 Out-of-State Services...III-7 Medically Necessary Services...III-7 Medical Assistance Providers...III-8 Eligible Providers...III-8 Non-Eligible Providers...III-9 Provider Enrollment Requirements...III-10 Eligible Recipients...III-11 Recipient Residency Requirements...III-11 One-Day/One-Month Eligibility...III-12 Eligibility Verification System (EVS)...III-12 Table III-3. Advantages of EVS...III-12 Medical Authorization: ID Cards and Coupons...III-12 Table III-4. Codes on Recipient s Card or Coupon...III-13 Medical Assistance Eligibility Codes...III-15 Table III-5. Medical Assistance Eligibility Codes...III-15 Chronic and Acute Medical Assistance (CAMA) Subtype...III-16 Table III-6. CAMA Eligibility Subtype...III-16 Resource Codes...III-16 Eligible Medical Assistance Recipients...III-18 Retroactive Eligibility for Eligible Medical Assistance Recipients...III-19 Eligible Chronic and Acute Medical Assistance (CAMA) Recipients...III-19 Regulations and Restrictions...III-20 Discriminatory Practices...III-20 Surveillance and Utilization Review for Fraud, Waste, Abuse, or Misuse...III-20 Medicaid Provider Fraud Control Unit...III-20 Timely Filing of Claims...III-21 Conditions for Payment...III-22 Recovery or Recoupment of an Overpayment...III-23 Appeals Process...III-24 UNDER REVISION: REFER TO 7 AAC Glossary... Glossary-1 Appendix A Directory Assistance... A-1 Appendix B Julian Date Calendar... B-1 Hospice xi

12 Appendix C Surveillance and Utilization Review Subsystem (SURS)... C-1 Appendix D Forms... D-1 Appendix E Transportation and Accommodation Resource Materials... E-1 Appendix F Telemedicine...F-1 Table of Contents Updated 03/05 xii Hospice

13 Section I Hospice Care Policies and Claims Billing Procedures UNDER REVISION: REFER TO 7 AAC Services The purpose of the hospice benefit is to provide for the palliation or management of the terminal illness and related conditions. The hospice benefit is available to a recipient who has been certified by a physician to be terminally ill. A recipient is considered to be terminally ill if he or she has a medical prognosis that his or her life expectancy is 6 months or less. Recipients who meet these requirements can elect the Medicaid hospice benefit. Hospice coverage is available for at least 210 days. The provision of care is generally in the home to avoid an institutional setting and to improve the individual s quality of life until he or she dies. However, recipients may reside in a nursing facility (NF) and receive hospice care in that setting. In order to be covered, a plan of care must be established before services are provided. The services must be related to the palliation or management of the patient s terminal illness, be related to symptom control, or be to enable the individual to maintain activities of daily living and basic functional skills. Continuous home care may be provided in a period of crisis. This consists of primarily nursing care to achieve palliation or management of acute medical symptoms. A minimum of eight hours of care, not necessarily consecutive, in a 24-hour day period is required. Also, short-term, inpatient care is covered, as long as it is provided in a participating hospice unit, a participating hospital, or a NF that additionally meets hospice standards. Services provided in an inpatient setting must conform to the written plan of care. General inpatient care may be required for procedures necessary for pain control, or acute or chronic symptom management, which cannot be provided in other settings. Respite care is short-term, inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. It may only be provided on an occasional basis and may not be reimbursed for more than five days at a time. Respite care may not be provided while the recipient is in a nursing home. All services must be performed by appropriately qualified personnel, but it is the nature of the service, rather than the qualification of the person who provides it, that determines the coverage category of the service. Table I-1 lists the services that are covered in the all-inclusive rates for the following Hospice Care revenue codes: 651-Routine Home Care 652-Continuous Home Care 653-Inpatient Respite Care 654-General Inpatient Care 659-Hospice Nursing Home Care While the patient is in the care of a hospice, billing for services in Table I-1 is restricted to the hospice only. These services, and Hospice Physician Services, are described in the following paragraphs. Refer to Reimbursement later in this section for revenue code and pricing methodology information. Hospice Care I-1

14 6. Counseling Services 1 Updated 03/05 Table I-1. Hospice Care Services 1. Nursing Care 1 2. Medical Social Services 1 3. Physical, Occupational, and Speech Therapy 4. Durable Medical Equipment, Supplies, Biologicals, and Drugs 5. Home Health Aide and Homemaker Services UNDER REVISION: REFER TO 7 AAC Services Consistent with the Written Plan of Care Any service rendered must be consistent with the written plan of care and is included in the reimbursement for the Hospice Care revenue code. Only the hospice can bill for services in Table I-1. The hospice medical director is responsible for the general supervision of services. Updated 03/05 Nursing Care Nursing care must be provided under the direction of a registered nurse. Updated 04/03 Medical Social Services Medical social services must be rendered by a social worker who has at least a bachelor s degree from a school accredited or approved by the Council on Social Work Education and who is working under the direction of a physician. Hospice Physician Services Updated 03/05 Hospice physician services are rendered by the hospice medical director or the physician member of the recipient s interdisciplinary group who is a licensed doctor of medicine or osteopathy and employed by the hospice. Physicians who are designated by recipients as the attending physician and who also volunteer services to the hospice are, as a result of their volunteer status, considered employees of the hospice. An attending physician who is not employed by the hospice or providing services under arrangements with the hospice may separately bill for services rendered. Physical Therapy, Occupational Therapy, and Speech Therapy Services covered are those provided for purposes of symptom control or to enable the individual to maintain activities of daily living and basic functional skills. Updated 03/05 Updated 8/96 1 Core services must be routinely provided by hospice employees. I-2 Hospice Care

15 Durable Medical Equipment, Medical Supplies, Biologicals, and Drugs Durable medical equipment, medical supplies, biologicals, and drugs that are used primarily for the relief of pain and symptom control of the recipient s terminal illness are covered. The hospice program interdisciplinary team/group may determine that certain biologicals and drugs are not used primarily for these purposes and should be covered separately by Medicaid and paid to a pharmacy provider. During its review of the hospice s plan of care, FHSC will evaluate the hospice program s determinations about drug coverage under the Medicaid hospice benefit. After the drug coverage review is complete, FHSC will send the decision, which identifies whether the pharmacy should bill Medicaid or the hospice program for the drugs, to the hospice program and to the pharmacy identified by the hospice program. Equipment is provided by the hospice while the recipient is under Hospice Care. Updated 03/05 UNDER REVISION: REFER TO 7 AAC Home Health Aide and Homemaker Services Home health aide and homemaker services must be provided in the recipient s home under the direction of a registered nurse. A registered nurse must visit the home at least every two weeks when aide services are being provided, and the visit must include an assessment of the aide services. Written instructions for patient care are prepared by a registered nurse. The home health aide provides services that are ordered by the physician in the plan of care and that the aide is permitted to perform under State law. The duties of a home health aide include the provision of hands-on personal care, performance of simple procedures as an extension of therapy or nursing services, assistance in ambulation or exercises, and assistance in administering medications that are ordinarily selfadministered. Any home health aide services offered by a home health agency must be provided by a qualified home health aide. Counseling Services Updated 03/05 Counseling services are provided to the recipient, family members, or caregiver to enable the family or caregiver to provide care and adjust to the recipient s approaching death. Counseling services must be available to both the individual and the family. Counseling includes bereavement counseling, provided after the patient s death, as well as dietary, spiritual and any other counseling services for the individual and family provided while the individual is enrolled in the hospice. There must be an organized program for the provision of bereavement services under the supervision of a qualified professional. The plan of care for these services should reflect family needs, as well as a clear delineation of services to be provided and the frequency of service delivery (up to one year following the death of the patient). Bereavement counseling is a required hospice service but is not reimbursable. Dietary counseling, when required, must be provided by a qualified individual. Spiritual counseling must include notice to patients as to the availability of clergy. The hospice must make reasonable efforts to arrange for visits of clergy and other members of religious organizations in the community to patients who request such visits and must advise patients of this opportunity. Counseling may be provided as determined by the hospice, by other members of the interdisciplinary group, or by other qualified professionals. Updated 03/05 Hospice Care I-3

16 Services in a Nursing Facility or Intermediate Care Facility for the Mentally Retarded Hospice Care can be provided to a recipient in a nursing facility or intermediate care facility for the mentally retarded if the recipient has elected Hospice Care and the hospice and the facility agree in writing on the responsibilities of each. Under the agreement, the hospice would have full responsibility for the professional management of the recipient s Hospice Care and the facility would provide, at a minimum: personal care services medication administration maintenance of the recipient s room supervision and assistance in the use of durable medical equipment supervision and assistance of prescribed therapies The facility must agree not to bill Alaska Medical Assistance for nursing facility care for a hospice recipient, but to accept the 95 percent of the daily rate reimbursed through the hospice. This agreement must be effective from the first day the recipient elects Hospice Care, through the hospice election or the recipient s death, unless the hospice election is terminated. Inpatient respite care is not available to a recipient in a nursing facility. Updated 04/03 UNDER REVISION: REFER TO 7 AAC Private Duty Nursing Services A recipient under age 21 may receive private duty nursing services rendered by or under the supervision of a registered nurse in a recipient s home in Alaska. EPSDT on File for Recipients Under 21 Updated 03/05 Recipients under 21 years of age 2 must receive an Early and Periodic Screening, Diagnosis and Treatment (EPSDT) screening within 12 months before hospice services begin. Providers may obtain information on whether an EPSDT screening is on file by contacting the referring provider or the EPSDT Office of the Department of Health and Social Services, Division of Health Care Services (see Appendix A). Medicare/Medical Assistance Hospice Election Dual Eligibles Updated 03/05 The Omnibus Budget Reconciliation Act of 1990 (OBRA 90) modified the Medicaid statute relating to hospice services. Prior to OBRA 90, when a Medicaid-eligible individual elected the Medicaid hospice benefit, he or she waived the right to Medicaid payment for services other than those described earlier. As modified, the law would allow an individual to receive payment for Medicaid services related to the treatment of the terminal condition and other medical services that would be equivalent to or duplicative of hospice care, so long as the services would not be covered under the Medicare hospice program. This means that Medicaid can cover certain services which Medicare does not cover. A recipient who is eligible for both Medicare and Medical Assistance must designate, change, or revoke a hospice simultaneously to both Medicare and Medical Assistance. Updated 03/05 2 Eligibility ends on the last day of the month in which Alaska Medical Assistance eligibility ends or on the last day of the month in which the individual becomes 21. I-4 Hospice Care

17 Documentation To consider reimbursement for Hospice Care, First Health Services must receive the following documentation: 1. Certification of the recipient s terminal illness 2. Election statement of the recipient or the recipient s parent or legal guardian 3. Copy of the recipient s plan of care Specific requirements for each type of documentation are given below. Updated 03/05 Certification of Terminal Illness FHSC must receive certification of the recipient s terminal illness within eight days after Hospice Care begins, signed by the medical director of the hospice and the recipient s attending physician. The certification must state that the recipient s medical prognosis is a life expectancy of six months or less, if the illness runs its normal course. The hospice must obtain the certification that an individual is terminally ill in accordance with the following procedures: For the first period of hospice coverage, the hospice must obtain, no later than two calendar days after hospice care is initiated, written certification statements signed by the medical director of the hospice or the physician member of the hospice interdisciplinary group and the individual s attending physician (if the individual has an attending physician). If the hospice does not obtain a written certification within two days after the initiation of hospice care, a verbal certification may be obtained within these 2 days, and a written certification must then be obtained no later than 8 days after care is initiated. If these requirements are not met, no payment can be made for days prior to the certification. The attending physician is a physician who is a doctor of medicine or osteopathy and is identified by the individual at the time he or she elects to receive hospice care as having the most significant role in the determination and delivery of the individual s medical care. For any subsequent period, the hospice must obtain, no later than two calendar days after the beginning of that period, a written certification statement prepared by the medical director of the hospice or the physician member of the hospice s interdisciplinary group. Election Statement Updated 03/05 FHSC must receive an election statement of the recipient or the recipient s parent or legal guardian that includes the following: 1. Name of the designated hospice. 2. Acknowledgment of a full understanding of Hospice Care. 3. Effective date of election. 4. Agreement to waive rights to other services, named below, for the duration of Hospice Care. a. Hospice Care by any other hospice (unless arranged through the designated hospice). b. Any other Medical Assistance services related to the recipient s terminal illness (unless provided by the designated hospice, by another hospice under arrangement with the designated hospice, or by the recipient s attending physician). 5. Option to revoke the recipient s election of Hospice Care at any time. 6. Option to change the designated hospice once in each election period. Hospice Care I-5

18 If a recipient elects to receive hospice care, he or she must file an election statement with a hospice. An election may also be filed by a representative acting pursuant to State law. With respect to an individual granted the power of attorney for the patient, State law determines the extent to which the individual may act on the patient s behalf. The election statement may be signed for a recipient under age 21 by the recipient s parent or legal guardian. An election to receive hospice care is considered to continue through the initial election period and through any subsequent election periods without a break in care as long as the individual remains in the care of the hospice and does not revoke the election. An individual may designate an effective date for the election period that begins with the first day of hospice care or any subsequent day of hospice care, but an individual may not designate an effective date that is earlier than the date that the election is made. An individual must waive all rights to Medicaid payments for the duration of the election of hospice care for the following services: Hospice care provided by a hospice other than the hospice designated by the individual (unless provided under arrangements made by the designated hospice); and Any Medicaid services that are related to the treatment of the terminal condition for which hospice care was elected or a related condition or that are equivalent to hospice care except for services Provided (either directly or under arrangement) by the designated hospice; Provided by the individual s attending physician if that physician is not an employee of the designated hospice or receiving compensation from the hospice for those services; or Provided as room and board by a nursing facility if the individual is a resident. After the hospice benefit expires, the patient s waiver of these other Medicaid benefits expires and coverage of certain services provided through the hospice may be possible. For example, if the hospice must provide acute inpatient care in a hospital with which it has an agreement, the hospital could bill Medicaid for covered hospital services. Updated 03/05 UNDER REVISION: REFER TO 7 AAC Written Plan of Care For Hospice Care services to be reimbursed, First Health Services must receive a written plan of care, as well as certification of the recipient s terminal illness and an election statement designating a hospice provider. The written plan of care must include an assessment of the recipient s needs and a detailed statement of the scope and frequency of services needed to meet the recipient s and family s needs (including biologicals and drugs used primarily for the relief of pain and symptom control of the terminal illness). First Health Services will issue a prior authorization number for an approved plan of care and forward to the provider. This number must be entered in Field 63 ( Treatment Authorization Codes ) of the claim form when filing for reimbursement. Refer to claim form instructions later in this section. Updated 03/05 Initial Plan of Care The recipient s initial plan of care must be written by a registered nurse or physician with at least one member of the interdisciplinary group designated to provide or supervise care and services offered by the hospice. A copy of the plan must be submitted to First Health Services within eight days after Hospice Care begins. Updated 03/05 I-6 Hospice Care

19 Comprehensive Plan of Care A written comprehensive plan of care must be developed, reviewed and updated (at intervals specified in the plan) by the hospice medical director or the recipient s attending physician and members of the interdisciplinary group. Updated 8/96 UNDER REVISION: REFER TO 7 AAC Interdisciplinary Group An interdisciplinary group must include a doctor of medicine or osteopathy, a registered nurse, a social worker, and a counselor. Updated 04/03 Prescribed Drugs: Prior Authorizations and Limitations The Division of Health Care Services (DHCS) may designate that specific drugs require the prescribing provider to obtain a prior authorization before the drug is dispensed. In an emergency, up to a 120-hour (5 day) supply of the drug may be dispensed before the drug has been authorized. Prior authorization requests for these drugs will be responded to within 24 hours of the request. If the prior authorization for the drug is approved, Alaska Medical Assistance will reimburse the provider for the drug, including the amount dispensed before the authorization was reviewed. If the prior authorization request is denied, Alaska Medical Assistance will not pay for the drug, including the amount dispensed before the authorization was reviewed. DHCS may also limit the allowed quantity (either minimum quantity or maximum quantity) of a specific prescribed drug or of a therapeutic drug class. The allowed number of refills for a specific prescribed drug or for a therapeutic drug class may also be limited by DHCS. Updated 08/03 Provider Participation Requirements An in-state hospice, which is a public or private organization certified by Medicare to primarily provide palliative care and services to the terminally ill, may enroll with the Alaska Division of Health Care Services (DHCS) to provide Hospice Care for Medical Assistance recipients in Alaska. DHCS will not enroll a hospice that is not in Alaska. A hospice physician who is employed by the hospice or providing services under arrangements with the hospice may enroll and bill for professional services by using his or her individual Medical Assistance provider identification number and designating the payment to the hospice. Enrolled providers are subject to the limits of Alaska state policy. In addition, provider services must be performed within the guidelines and restrictions of the Medical Assistance program. See Section III for general enrollment requirements. The hospice and all hospice employees must be licensed in accordance with applicable Federal and State laws. Updated 03/05 Hospice Care I-7

20 Recipient Eligibility Verification Before rendering services, the provider is responsible for verifying the following: the age of the recipient that the recipient is Medical Assistance-eligible and also eligible for the specific services that the services are covered by Medical Assistance Age and eligibility can be verified by telephoning FHSC s automated Eligibility Verification System (EVS), described in Section III. EVS is time-saving and cost-effective (see Table I-2, Advantages of EVS ). Table I-2. Advantages of EVS 1. Verifies recipient s month of eligibility. 2. Provides recipient s Medical Assistance identification number by use of recipient s Social Security Number. 3. Identifies any third party liability (i.e., insurance). 4. Accessible 24 hours, 7 days a week. The provider can also verify the patient s age and eligibility by: Checking the patient s Medical Assistance identification card or coupon (refer to Section III for samples). Telephoning Provider Inquiry of the Provider Services Unit. See Page v for telephone numbers. Eligibility Codes Updated 10/03 Recipients with the Medical Assistance eligibility codes in Table I-3 are eligible to receive Hospice Care. Table I-3. Eligibility Codes for Hospice Services Code Category 10 Public Health Service (IHS, AANHS, and CHAMPUS) 11 Pregnant Woman (Alaska Healthy Baby Program) 20 No Other Eligibility Codes Apply 30 Adult Disabled, Waiver Only 31 Adult Disabled, Waiver Medical 34 Adult Disabled, Waiver Adult Public Assistance/Qualified Medicare Beneficiary 40 Older Alaskan, Waiver Only 41 Older Alaskan, Waiver Medical 44 Older Alaskan, Waiver Adult Public Assistance/Qualified Medicare Beneficiary 50 Under Juvenile Court Ordered Custody of Health and Social Services 52 Transitional Medical Assistance I-8 Hospice Care

21 Code Category 54 Disabled/Supplemental Security Income (SSI) Child 67 Qualified Medicare Beneficiary (QMB) Only - Eligible Only for Medical Assistance Payment of Medicare Deductible and Coinsurance for Medicare-covered Services 69 Adult Public Assistance (APA)/Qualified Medicare Beneficiary (QMB) - (Dual Eligibility) 70 Mental Retardation and Developmental Disabilities, Waiver Only 71 Mental Retardation and Developmental Disabilities, Waiver Medical 74 Mental Retardation and Developmental Disabilities, Waiver Adult Public Assistance and Qualified Medicare Beneficiary 80 Children with Medically Complex Conditions, Waiver Only 81 Children with Medically Complex Conditions, Waiver Medical Updated 03/05 Hospice Care I-9

22 Reimbursement General Timely Filing All claims must be filed within 12 months of the date services were provided to the recipient. The 12- month timely filing limit applies to all claims, including those that must first be filed with a third-party carrier. In these cases, providers must bill Medical Assistance within 12 months of the service date and attach explanation of benefits documentation from the third-party carrier to the Medical Assistance claim. Timely filing of claims is discussed in greater detail in Section III. Updated 08/03 Pricing Methodology Under the Medicaid hospice benefit, no cost sharing may be imposed with respect to hospice services rendered to Medicaid recipients. With the exception of payment for physician services, Medicaid reimbursement for hospice care will be made at one of four predetermined rates for each day in which an individual is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments, other than the limitation on payments for inpatient care, if applicable. Payment rates are adjusted for regional differences in wages. The Centers for Medicare and Medicaid Services (CMS) publishes an annual change to the Medicaid hospice payment rates. The rates are then calculated by applying an urban and rural hospice wage index for Alaska that is published annually in the federal register. The federal fiscal year 2006 Medicaid hospice rates, after area wage adjustments for each of the categories of care are: Urban Rural Routine Home Care Daily Rate $ $ Continuous Home Care Hourly Rate $37.61 $37.80 Inpatient Respite Care Rate $ $ General Inpatient Care Rate $ $ Updated 11/06 Payment if a Recipient Resides in a Nursing Facility If a recipient resides in a nursing facility (NF), an additional payment is made to the hospice that is equal to 95 percent of the NF rate to pay for the room and board services provided by the NF. In this context, the term room and board includes performance of personal care services, including assistance in the activities of daily living, socializing activities, administration of medication, maintaining the cleanliness of a resident s room, and supervision and assisting in the use of durable medical equipment and prescribed therapies. The hospice reimburses the facility for these services. Payments to a Hospice for Private Duty Nursing Services Updated 03/05 Payment for private duty nursing services in a recipient s home will be made at the in-state rates established under 7 AAC Alaska Medical Assistance will not reimburse for out-of-state private duty nursing services provided during hospice care for recipients under 21. Refer to the Private Duty Nursing Services provider billing manual for billing instructions. Updated 03/05 I-10 Hospice Care

23 Payments to a Hospice for Inpatient Care Payment to a hospice for inpatient respite care is limited to five days at a time including the date of admission but not counting the date of discharge. The sixth and any subsequent days are reimbursed at the routine home care rate. The day of discharge from an inpatient unit is reimbursed at the appropriate (routine or continuous) home care rate, unless the patient dies as an inpatient. If the patient is discharged deceased, the appropriate (general or respite) inpatient rate is paid for the discharge date. Payments to a hospice for inpatient care must be limited according to the number of days of inpatient care furnished under Medicaid. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid recipients by the hospice during that period. Hospice care provided to recipients with AIDS is not included in this calculation. For purposes of this computation, if it is determined that the inpatient rate should not be paid, any days for which the hospice receives payment at a home care rate are not counted as inpatient days. Calculate the limitation as follows: The maximum allowable number of inpatient days is calculated by multiplying the total number of days of Medicaid hospice care by 0.2. If the total number of days of inpatient care furnished to Medicaid hospice patients is less than or equal to the maximum, no adjustment is necessary. If the total number of days of inpatient care exceeds the maximum allowable number, the limitation is determined by 1. calculating a ratio of the maximum allowable days to the number of actual days of inpatient care, and multiplying this ratio by the total reimbursement for inpatient care (general inpatient and inpatient respite reimbursement), 2. multiplying excess inpatient care days by the routine home care rate, 3. adding together the amounts calculated in 1 and 2, and 4. comparing the amount in 3 with interim payments made to the hospice for inpatient care during the 12-month period. Any excess reimbursement is refunded by the hospice. Updated 03/05 UNDER REVISION: REFER TO 7 AAC Physician Services A patient s independent attending physician, who is not employed by the hospice nor providing services under arrangements with the hospice, may bill for professional services using his or her individual Medical Assistance provider identification number. The hospice must notify First Health of the election and the name of the physician who has been designated as the attending physician whenever the attending physician is not a hospice employee. Reimbursement is made to an independent attending physician in accordance with 7 AAC Payment is made to the hospice for physicians services that are direct patient care services, furnished to individual recipients by hospice employees, including the hospice medical director, and for physician services furnished under arrangements made by the hospice unless the patient care services was furnished on a volunteer basis. The hospice may be reimbursed in accordance with 7 AAC This reimbursement is in addition to the daily rates. Physicians who are designated by recipients as the attending physician and who also volunteer services to the hospice are, as a result of their volunteer status, considered employees of the hospice. All direct Hospice Care I-11

24 patient care services rendered by these physicians to hospice patients are hospice physician services, and are reimbursed to the hospice. Reimbursement is made to the hospice on behalf of a volunteer physician for specific services rendered which are not furnished on a volunteer basis (a physician may seek reimbursement for some services while furnishing other services on a volunteer basis). The hospice must reimburse the physician for those physician services rendered. In determining which services are furnished on a volunteer basis and which services are not, a physician must treat Medicaid patients on the same basis as other patients in the hospice. For instance, a physician may not designate all physician services rendered to non-medicaid patients as volunteered and at the same time seek payment from the hospice for all physician services rendered to Medicaid patients. Refer to the Physician Services provider billing manual for billing instructions. Updated 03/05 UNDER REVISION: REFER TO 7 AAC Revenue Codes Use the revenue codes below to bill for the Hospice Care services listed and described earlier in this section. Each of the following revenue codes will have a separate rate. Note: The sum of the days and hours represented by Revenue Codes 651 through 654 cannot exceed the spanned dates of service. In addition, units of service for Revenue Code 659 cannot exceed days included on the claim. Updated 03/05 Daily Rate Separate daily (per diem) rates (1 Unit=1 Day) are set for routine home care, inpatient respite care, general inpatient care, and hospice nursing home care as follows: Routine Home Care. Revenue Code 651. Hospice Care at home that is not continuous care. Inpatient Respite Care. Revenue Code 653. Hospice Care in an approved facility on a shortterm basis for respite; limited to five consecutive days. General Inpatient Care. Revenue Code 654. Hospice Care in a general inpatient setting for pain control or acute or chronic symptom management, which cannot be managed in any other setting. Hospice Nursing Home Care. Revenue Code 659. Hospice Care in a nursing home facility or intermediate care facility for the mentally retarded under agreement with the hospice. Prior to billing Revenue Code 659, forward a copy of the agreement with the facility to First Health Services Corporation, Attention: Prior Authorization. If the hospice has an agreement with more than one nursing home facility or intermediate care facility for the mentally retarded, forward a copy of each facility agreement, as above, before billing Revenue Code 659. When appropriate, this revenue code may be billed in conjunction with Revenue Code 651 or 652. Hourly Rate An hourly rate (1 Unit=1 Hour) is set for continuous home care as follows: Updated 03/05 Continuous Home Care. Revenue Code 652. Hospice Care provided only during a period of crisis, when the recipient requires constant care to reduce or manage acute medical symptoms necessary to maintain the recipient at home. To qualify as continuous home care, a minimum of eight hours of care per 24-hour period must be provided and more than half of the care must be nursing care. Updated 8/96 I-12 Hospice Care

25 TPL (Third Party Liability) Alaska Medical Assistance is the payer of last resort. Providers who bill Alaska Medical Assistance are required to bill all third party resources (except IHS) prior to billing Alaska Medical Assistance. However, if the services provided fall under the Federal TPL Waiver, Alaska Medical Assistance will seek reimbursement from the third party. Updated 04/03 Federal TPL Waiver Alaska Medical Assistance has been granted a Federal TPL Waiver for certain providers that offer specific categories of service. At this time, providers who offer the services listed below are not required to bill third party resources: Pharmacy services Dental services Transportation and accommodation services (except Air Ambulance and Ground Ambulance services) Home and Community Based Waiver provider services Personal Care Assistant services EPSDT screening services Prenatal Care services Preventive Pediatric services Eye wear (lenses/frames - This applies only to the contract supplier of eyewear.) If you provide one (or more) of the services listed above, you are not required to bill a third party resource before you bill Alaska Medical Assistance. Alaska Medical Assistance will reimburse you up to the allowed amount and then seek reimbursement from the third party. You may choose to bill the third party resource if the service provided is covered by that resource and the payment will exceed the expected Alaska Medical Assistance reimbursement amount. Providers who offer services that are not listed above are required to bill all third party resources (except IHS) before billing Alaska Medical Assistance, and include all TPL resource payments on Alaska Medical Assistance claims. Recipients with VA, Medicare, and Medicaid Updated 10/03 Alaska Medical Assistance (Medicaid) is always the payer of last resort. Therefore, if a patient is eligible for VA, Medicare, and Medicaid, all VA and Medicare benefits must be exhausted or you must submit valid documentation of non-coverage from VA or Medicare before you bill Alaska Medical Assistance. Valid documentation may include an Explanation of Benefits showing non-coverage or a Medicaid Denial Letter from the Veteran s Administration (refer to Obtaining a VA Medicaid Denial Letter below for additional information). A Medical Assistance recipient who is eligible for VA and Medicare can use either as his/her primary resource. However, the following conditions apply in regards to Alaska Medical Assistance paying anything for the claim: If VA is pursued as the recipient s primary payer (instead of Medicare), the claim is considered satisfied, and neither Medicare nor Medicaid will pay anything more. Hospice Care I-13

26 If Medicare is pursued as the recipient s primary payer (instead of VA), 1. VA will not pay for anything over the amount paid by Medicare. 2. Alaska Medical Assistance may pay the Medicare co-pay and/or deductible if the Medicare Remittance Notice (MRN) and the VA denial are attached to the claim. 3. Alaska Medical Assistance may reimburse according to the applicable Alaska Medical Assistance rates if the services billed are non-covered Medicare services and a Medicaid Denial Letter from the VA is attached to the PA request and/or claim. (Refer to Obtaining a VA Medicaid Denial Letter below.) Therefore, if a recipient is eligible for VA, Medicare, and Medicaid, Alaska Medical Assistance will not pay anything for the claim unless you have followed these steps: 1. Bill VA first and receive a formal denial (in writing) from VA or receive a Medicaid Denial Letter. UNDER REVISION: REFER TO 7 AAC Note: If you have an applicable Medicaid Denial Letter from the VA, you do not have to bill VA first. Refer to Obtaining a VA Medicaid Denial Letter below. 2. Bill Medicare correctly. 3. Bill Alaska Medical Assistance correctly and attach the denial from VA and the Medicare Remittance Notice (MRN). If these steps are followed and if the claim is billed correctly, Alaska Medical Assistance may pay the Medicare co-pay and/or deductible. Explanation VA is considered primary because they pay 100% of their allowed amount. Medicare is considered secondary because they pay 80% of their allowed amount with a 20% co-pay, which Alaska Medical Assistance can cover under the correct billing process. However, Alaska Medical Assistance will not use state funds for a 20% Medicare co-pay if the claim could have been satisfied with 100% federal funds (VA is federally funded). Please refer to the back of the CMS-1500 claim form ( Refers to Government Programs Only ) for rules and information related to billing multiple federally funded programs. Obtaining a VA Medicaid Denial Letter Updated 04/04 To provide freedom of choice for veterans with medical needs, the veteran can request a Medicaid Denial Letter from the Veteran s Administration. This letter, which is for specific services, can be submitted to the Alaska Medical Assistance program as an explanation of Veteran benefits. Therefore, if the veteran chooses not to use VA as his/her primary payer, you should attach a copy of this letter to any related prior authorization requests and/or claims sent to Alaska Medical Assistance. Important: All other Medical Assistance billing requirements still apply to claims submitted with a Medicaid Denial Letter, including Timely filing of claims Exhaustion of all other benefit resources (including Medicare) before billing Medical Assistance I-14 Hospice Care