Hospice Care Services. Medicaid and Other Medical Assistance Programs

Transcription

1 Hospice Care Services Medicaid and Other Medical Assistance Programs January 2005

2 This publication supersedes all previous Hospice Care Services manuals. Published by the Montana Department of Public Health & Human Services, July Updated January CPT codes, descriptions and other data only are copyright 1999 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Apply. My Medicaid Provider ID Number:

3 Hospice Care Services Replacement Original Page, Page, January July Table of Contents Table of Contents...i.1 Key Contacts...ii.1 Introduction Manual Organization Manual Maintenance Rule References Claims Review (MCA , ARM ) Getting Questions Answered Covered Services General Coverage Principles Services provided by the hospice (ARM ) Services provided by physicians (ARM ) Services provided by contract staff (42 CFR ) Non-covered services Client Enrollment Coverage of Specific Services Counseling services Crisis services Home health aide services Inpatient hospice care Inpatient respite care Medical supplies Nursing services Physician services Social worker services Therapy services Other Programs Mental Health Services Plan (MHSP) Children s Health Insurance Plan (CHIP) Coordination of Benefits When Clients Have Other Coverage Identifying Additional Coverage When a Client Has Medicare Medicare claims When a Client Has TPL (ARM ) Exceptions to billing third party first Requesting an Exemption When the Third Party Pays or Denies a Service When the Third Party Does Not Respond Table of Contents i.1

4 Replacement Original Page, Page, July 2004 January 2005 Hospice Care Services Billing Procedures Claim Forms Timely Filing Limits (ARM ) Tips to avoid timely filing denials When To Bill Medicaid Clients (ARM ) Client Cost Sharing When Clients Have Other Insurance Billing for Retroactively Eligible Clients Using the Medicaid Fee Schedule Coding Billing For Hospice Services Routine home care day Continuous home care Inpatient respite day General inpatient day Board and room for nursing facility residents Billing For Physician Services Hospice Cap The Most Common Billing Errors and How to Avoid Them Submitting a Claim Electronic Claims Billing Electronically with Paper Attachments Paper Claims Completing a UB-92 Claim Form Mailing Paper Claims Claim Inquiries Avoiding Claim Errors Remittance Advices and Adjustments The Remittance Advice Electronic RA Paper RA Key to the Paper RA Credit balance claims Rebilling and Adjustments How long do I have to rebill or adjust a claim? Rebilling Medicaid When to rebill Medicaid How to rebill Adjustments When to request an adjustment How to request an adjustment Completing an Adjustment Request Form Mass adjustments Payment and The RA i.2 Table of Contents

5 Hospice Care Services Replacement Original Page, Page, January July How Payment Is Calculated Overview Hospice Rates Calculating rates Calculating payment Caps Inpatient cap Overall cap Appendix A...A.1 Physician s Certification for Medicaid Hospice Benefit...A.2 Patient Election for Medicaid Hospice Services by Hospice and Assignment Benefits...A.3 Paperwork Attachment Cover Sheet...A.4 Montana Medicaid Claim Inquiry Form...A.5 Montana Medicaid Individual Adjustment Request...A.6 Definitions and Acronyms...B.1 Index...C.1 Table of Contents i.3

6 Original Page, July 2004 Hospice Care Services i.4 Table of Contents

7 Hospice Care Services Original Page, July 2004 Key Contacts Hours for Key Contacts are 8:00 a.m. to 5:00 p.m. Monday through Friday (Mountain Time), unless otherwise stated. The phone numbers designated In state will not work outside Montana. Provider Relations For questions about eligibility, payments, denials, general claims questions, Medicaid or PASSPORT provider enrollment, address or phone number changes, or to request provider manuals or fee schedules: (800) In state (406) Out of state and Helena Send written inquiries to: Provider Relations Unit P.O. Box 4936 Helena, MT Claims Send paper claims to: Claims Processing Unit P. O. Box 8000 Helena, MT Client Eligibility For client eligibility, see the Client Eligibility and Responsibilities chapter in the General Information For Providers manual. Senior and Long Term Care For hospice program information: (406) Phone (406) Fax Send written inquiries to: Senior and Long Term Care P.O. Box 4210 Helena, MT Third Party Liability For questions about private insurance, Medicare or other third-party liability: (800) In state (406) Out of state and Helena (406) Fax Send written inquiries to: ACS Third Party Liability Unit P. O. Box 5838 Helena, MT Provider s Policy Questions For policy questions, contact the appropriate division of the Department of Public Health and Human Services; see the Introduction chapter in the General Information For Providers manual. Technical Services Center Providers who have questions or changes regarding electronic funds transfer should call the number below and ask for the Direct Deposit Manager. (406) ACS EDI Gateway For questions regarding electronic claims submissions: (800) Phone (850) Fax ACS EDI Gateway Services 2324 Killearn Center Blvd. Tallahassee, FL Key Contacts ii.1

8 Original Replacement Page, Page, July 2004 January 2005 Hospice Care Services Secretary of State The Secretary of State s office publishes the most current version of the Administrative Rules of Montana (ARM): (406) Phone Secretary of State P.O. Box Helena, MT ii.2 Key Contacts

9 Hospice Care Services Replacement Original Page, Page, January July Key Web Sites Web Address Information Available Virtual Human Services Pavilion (VHSP) vhsp.dphhs.mt.gov Provider Information Website or Medicaid Mental Health and Mental Health Services Plan addictive_mental_disorders/services/ public_mental_health_services.htm Senior and Long Term Care ACS EDI Gateway montana.htm Select Human Services for the following information: Medicaid: Medicaid Eligibility & Payment System (MEPS). Eligibility and claims history information. Senior and Long Term Care: Provider search, home/housing options, healthy living, government programs, publications, protective/legal services, financial planning. DPHHS: Latest news and events, Mental Health Services Plan information, program information, office locations, divisions, resources, legal information, and links to other state and federal web sites. Health Policy and Services Division: Children s Health Insurance Plan (CHIP), Medicaid provider information such as manuals, newsletters, fee schedules, and enrollment information. Medicaid Information Medicaid news Provider manuals Notices and manual replacement pages Fee schedules Remittance advice notices Forms Provider enrollment Frequently asked questions (FAQs) Upcoming events Electronic billing information Newsletters Key contacts Mental Health Services information for Medicaid and MHSP Provider Search Home/Housing Options Healthy Living Government Programs Publications Protective/Legal Services Financial Planning ACS EDI Gateway is Montana s HIPAA clearinghouse. Visit this website for more information on: Provider Services EDI Support Enrollment Manuals Software Companion Guides Washington Publishing Company Key Contacts EDI implementation guides HIPAA implementation guides and other tools EDI education ii.3

10 Original Page, July 2004 Hospice Care Services ii.4 Key Contacts

11 Hospice Care Services Replacement Original Page, Page, January July Introduction Thank you for your willingness to serve clients of the Montana Medicaid program and other medical assistance programs administered by the Department of Public Health and Human Services. Manual Organization This manual provides information specifically for providers of hospice services. Additional essential information for providers is contained in the separate General Information For Providers manual. Each provider is asked to review both manuals. A table of contents and an index allow you to quickly find answers to most questions. The margins contain important notes with extra space for writing notes. Each manual contains a list of Key Contacts at the beginning. We have also included a space on the back side of the front cover to record your Medicaid Provider ID number for quick reference when calling Provider Relations. Manual Maintenance Manuals must be kept current. Changes to manuals are provided through notices and replacement pages. When replacing a page in a manual, file the old pages and notices in the back of the manual for use with claims that originated under the old policy. Rule References Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. In the event that a manual conflicts with a rule, the rule prevails. Links to rules are available on the Provider Information website (see Key Contacts). Paper copies of rules are available through Provider Relations, the Department (Senior and Long Term Care) and the Secretary of State s office (see Key Contacts). In addition to the general Medicaid rules outlined in the General Information For Providers manual, the following rules and regulations are also applicable to the hospice program: Code of Federal Regulations (CFR) 42 CFR 418 Hospice Care Montana Codes Annotated (MCA) MCA Montana Medicaid Program Authorization of Services Providers are responsible for knowing and following current laws and regulations. Introduction 1.1

12 Original Replacement Page, Page, July 2004 January 2005 Hospice Care Services Administrative Rules of Montana (ARM) ARM Hospice Claims Review (MCA , ARM ) The Department is committed to paying Medicaid provider s claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were appropriately billed. Although the computerized system can detect and deny some erroneous claims, there are many erroneous claims which it cannot detect. For this reason, payment of a claim does not mean that the service was correctly billed or the payment made to the provider was correct. Periodic retrospective reviews are performed which may lead to the discovery of incorrect billing or incorrect payment. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid or the claim was erroneous in some other way, the Department is required by federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of Department or provider error or other cause. Getting Questions Answered The provider manuals are designed to answer most questions; however, questions may arise that require a call to a specific group (such as a program officer or Provider Relations). The list of Key Contacts at the front of this manual has important phone numbers and addresses pertaining to this manual. The Introduction chapter in the General Information For Providers manual also has a list of contacts for specific program policy information. Medicaid manuals, notices, replacement pages, fee schedules, forms, and much more are available on the Provider Information website (see Key Contacts). 1.2 Introduction

13 Hospice Care Services Original Page, July 2004 Covered Services General Coverage Principles Hospice programs provide health and support services to terminally ill clients and their families. These programs focus on palliative rather than curative care to help the client and those closest to the client come to terms with the terminal condition and live the remaining life as fully as possible. When a client selects hospice, he or she waives all Medicaid benefits related to curative care. The client may receive palliative services provided by the designated hospice, the client s attending physician, or room and board by a nursing facility if the client is a resident. This chapter provides information on covered services supplied by hospice providers. Like all health care services received by Medicaid clients, services provided by hospice providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information For Providers manual. Services provided by the hospice (ARM ) The hospice must be licensed under state law. The hospice must meet Medicare s conditions of participation and have a valid provider agreement with Medicare. The hospice must provide the Department with a list of physician volunteers and physicians employed by the hospice. This list must be kept current. The hospice must notify the Department when the client s attending physician is not a hospice employee. Services provided by physicians (ARM ) Physician services are defined as those services provided by individuals licensed under their state medical practice act to practice medicine or osteopathy. Services provided by contract staff (42 CFR ) A hospice may use contracted staff to supplement hospice employees during periods of peak client loads or other extraordinary circumstances. The hospice remains responsible for the quality or services provided by contracted staff. Non-covered services Medicaid will not pay separately for palliative services. It is the responsibility of the hospice to provide all palliative treatment, which is included in the hospice daily rate. Covered Services 2.1

14 Original Page, July 2004 Hospice Care Services Services used for curative care are not covered by the hospice or by Medicaid for hospice clients. For example, chemotherapy and radium are not covered for curative purposes but may be provided by the hospice when the purpose is to make the client more comfortable. Services provided by a hospice other than the elected hospice are not covered. However, services provided by a provider (or another hospice) other than the hospice or the client s attending physician are only covered when the hospice has a contract with the provider. Medicaid does not cover physician services provided on a volunteer basis. Client Enrollment Hospice services are covered only for Medicaid clients enrolled in the hospice program. The following are client enrollment policies. The Medicaid client must be certified as terminally ill, and certification must be submitted to Medicaid (see Physician s certification in following table). During the election process, the hospice must explain the benefits the client will receive and those the client is waiving (see Election statement in following table). The hospice must establish a plan of care for the client (see Plan of care in following table). A client may receive hospice care until he or she is no longer certified as terminally ill or until the election of hospice is revoked (see Revocation statement in following table). The hospice must obtain certification of the client s terminal illness for two consecutive 90-day periods followed by an unlimited number of 60-day periods (see Physician s certification statement and Physician s recertification statement in following table). A client may change hospice providers once in each election period. The client submits a signed statement identifying the current hospice and the newly designated hospice. This statement must give the effective date of change. Both hospices must retain copies of this statement. A client may revoke the election of hospice at any time. After revoking hospice election, the client may receive any Medicaid benefits previously waived when hospice care was chosen. A Medicaid client may elect hospice again at any time as long as the client meets the hospice eligibility requirements. A client may live either in his or her home in the community or in a nursing facility while receiving hospice services. Hospice providers must provide their own forms which must meet the requirements shown in the following table. See also the Provider Requirements chapter in this manual. 2.2 Covered Services

15 Hospice Care Services Original Page, July 2004 Hospice Form Requirements See Appendix A For Sample Forms Form Requirements Plan of care Election statement Revocation statement Physician s certification statement Physician s recertification statement The interdisciplinary group must assess the client s needs and develop a written plan of care. The group member who writes the plan must confer with at least one physician or nurse member of the group while developing the plan. The other group members must review the client s plan of care. The hospice must provide services in accordance with the plan. The election statement must include the following: Name of the hospice that will provide care. An acknowledgment that the client understands that hospice provides palliative care, not curative, for the terminal illness. An acknowledgment that certain other Medicaid services are being waived when hospice is elected. The client s or representative s signature. A representative may be used for a client who is physically or mentally incapacitated. The representative may sign the election statement, sign the waiver of benefits or revocation statements, or change hospice providers on behalf of the client. The hospice must submit a copy of the election statement(s) to the Department s Senior and Long Term Care Division (see Key Contacts), and give a copy to the client. The revocation statement must include the following: Effective date for the revocation of Medicaid hospice care. The client s or representative s signature. The effective date of the revocation must be on or after the date the form is signed. Copy of form must be mailed to the Department s Senior and Long Term Care Division (see Key Contacts) within two business days after hospice receives the statement. The hospice obtains and documents the certification of terminal illness. The certification must be obtained verbally within two calendar days after hospice care is initiated. Written certification must be obtained before billing Medicaid for services. Failure to obtain certification in a timely manner may result in the provider repaying the Department for claims. The initial certification is for 90 days. The initial certification must be signed by the medical director of the hospice or the physician member of the interdisciplinary group and the client s attending physician, if he or she has one. The hospice must obtain a recertification statement stating that the client is terminally ill. Verbal recertification must be obtained within two calendar days from the beginning of each subsequent benefit period as defined by Medicare regulations. Written certification must be on file before submitting a claim. Failure to obtain recertification in a timely manner may result in the provider repaying the Department for claims. The form must be signed by the medical director of the hospice or the physician member of the hospice s interdisciplinary group or the client s attending physician, if he or she has one. Certification and the first recertification periods are for 90 days and can be followed by an unlimited number of 60-day extensions. Covered Services 2.3

16 Original Page, July 2004 Hospice Care Services When a client is receiving short-term care in a nursing facility during a crisis period, 24-hour nursing services must be provided for the client. Coverage of Specific Services The hospice must provide all services necessary for the palliation or management of the terminal illness and related conditions. Medicaid generally covers services that are covered under Medicare. In cases where Medicaid and Medicare policies are different, Medicaid policy applies. Medicaid also covers non-curative services that are not provided by the designated hospice such as insulin for diabetics. A hospice is required to provide the following services through the hospice or under contract with another provider. All palliative services, including the following, are included in the daily rate. Counseling services Counseling services are provided to the client and the family members or others caring for the client at the client s home. The hospice will train the client s family or other caregiver to provide care and to help the client and those caring for the client to adjust to the person s approaching death. Counseling services also include dietary, spiritual, bereavement, and other counseling. Bereavement counseling is provided for up to one year following the client s death and is available to the client s family and those close enough to the client to be considered family. Crisis services Continuous home care is provided only during a period of crisis. A period of crisis is a period in which a person requires continuous care to achieve palliation or management of acute medical symptoms. Nursing care during a crisis must be provided by a registered nurse or licensed practical nurse. A minimum of eight hours of nursing care must be provided during a 24-hour day, with more than 50% of the care provided by licensed nurses. Home health aide and homemaker services may also be provided to supplement the nursing care during a period of crisis. The eight hours of nursing care does not have to be contiguous throughout the 24-hour period. Home health aide services Home health aides may provide personal care services such as bathing, dressing, grooming, etc. Aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the client, such as changing bed linens or light cleaning and laundering essential to the comfort and cleanliness of the client. Aide services must be provided under the general supervision of a registered nurse. Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the provider to carry out the treatment plan. 2.4 Covered Services

17 Hospice Care Services Original Page, July 2004 Inpatient hospice care Inpatient hospice care is provided when a client s symptoms become too severe for caregivers to manage at home. Inpatient hospice care includes procedures necessary for pain control or acute or chronic symptoms management. Care must be provided in a Medicaid/Medicare certified hospital or a skilled nursing facility under contract with the hospice. Inpatient respite care The hospice may provide inpatient respite care for the client s family or others caring for the client at home. The facility must also provide treatments, medications, and diet as prescribed. Inpatient respite care must be provided in an inpatient hospice unit or a Medicaid/Medicare certified hospital or nursing facility under contract with the hospice. The hospice is paid for up to five consecutive days of respite care at a time. Medicaid does not cover respite care when the client lives in a nursing facility. Medical supplies Medical appliances, durable medical equipment and supplies including drugs and biologicals, and other self-help and personal comfort items related to the palliation or management of the client s terminal illness are included in the hospice payment. The hospice must provide these supplies for use in the client s home while he or she is receiving hospice care. Medical supplies must be specified in the written plan of care. When a client requires medication that is not related to their terminal condition and not curative (e.g., insulin), it will be covered by the client s Medicaid pharmacy benefits. Nursing services The hospice must employ a registered nurse to coordinate client care so that all the client s needs are met. During a crisis period (see Definitions), nursing services must be provided directly to the client by a registered nurse (see Crisis services earlier in this chapter). Inpatient hospice and respite facilities must have a registered nurse available within the facility 24 hours a day. Physician services The hospice must employ a physician as the hospice director and/or to provide medical care that is not being met by the client s attending physician. These services are included in hospice daily rate and are not billed separately. Services provided by the client s attending physician are covered when the services are palliative only and not related to the treatment of the terminal (or related) condition for which the hospice care was elected. For example, a client who has diabetes may be treated for it by his or her attending physician. All drugs directly related to the terminal condition or for pain are prescribed by the client s attending physician (or hospice director if the client has no attending physician) and supplied by the hospice. When the client is treated by his or Covered Services 2.5

18 Original Page, July 2004 Hospice Care Services her attending physician, the physician bills Medicaid separately from the hospice and this fee is not included in the hospice cap. When billing Medicaid for physician services, refer to the Physician Related Services manual. Social worker services Medical social services must be provided 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. Therapy services Physical therapy, occupational therapy, and speech/language pathology services may be provided to maintain activities of daily living and basic functional skills. Other Programs This is how the information in this manual applies to Department programs other than Medicaid. Mental Health Services Plan (MHSP) The information in this manual does not apply to the Mental Health Services Plan (MHSP). Clients who qualify for MHSP may receive mental health services during hospice care. For more information on the MHSP program, see the Mental Health Manual available on the Provider Information website (see Key Contacts). Children s Health Insurance Plan (CHIP) The information in this manual does not apply to CHIP clients. For a CHIP medical manual, contact BlueCross BlueShield of Montana at (800) x8647. Additional information regarding CHIP is available on the CHIP website (see Key Contacts). 2.6 Covered Services

19 Hospice Care Services Original Page, July 2004 Coordination of Benefits When Clients Have Other Coverage Medicaid clients often have coverage through Medicare, workers compensation, employment-based coverage, individually purchased coverage, etc. Coordination of benefits is the process of determining which source of coverage is the primary payer in a particular situation. In general, providers should bill other carriers before billing Medicaid, but there are some exceptions (see Exceptions to Billing Third Party First in this chapter). Medicare is processed differently than other sources of coverage. Identifying Additional Coverage The client s Medicaid eligibility verification may identify other payers such as Medicare or other third party payers (see the General Information For Providers manual, Client Eligibility and Responsibilities). If a client has Medicare, the Medicare ID number is provided. If a client has additional coverage, the carrier is shown. Some examples of third party payers include: Private health insurance Employment-related health insurance Workers Compensation Insurance* Health insurance from an absent parent Automobile insurance* Court judgments and settlements* Long term care insurance *These third party payers (and others) may not be listed on the client s eligibility verification. Providers should use the same procedures for locating third party sources for Medicaid clients as for their non-medicaid clients. Providers cannot refuse service because of a third party payer or potential third party payer. When a Client Has Medicare Medicare claims are processed and paid differently than other non-medicaid claims. The other sources of coverage are called third party liability, but Medicare is not. Coordination of Benefits 3.1

20 Original Page, July 2004 Hospice Care Services Medicare claims Medicare Part A covers hospice services. Any claims for services covered by Medicare must be submitted to Medicare before submitting to Medicaid. After Medicare processes the claim, an Explanation of Medicare Benefits (EOMB) is sent to the provider, and the provider can then bill Medicaid. When the provider knows Medicare will not cover services at a particular time, the claim does not need to be submitted to Medicare first. Providers may submit the claim directly to Medicaid and certify that Medicare is not covering the service by writing Force Exc Hospice Room & Board in form locator (FL) 84 of the UB-92 claim form. This exact wording must be used and written in dark ink, or the claim will be denied. When submitting electronic claims with paper attachments, see the Billing Electronically with Paper Attachments section of the Submitting a Claim chapter. When submitting a claim with the Medicare EOMB, use Medicaid billing instructions and codes. Medicare s instructions, codes, and modifiers may not be the same as Medicaid s. The claim must also include the Medicaid provider number and Medicaid client ID number. When a Client Has TPL (ARM ) When a Medicaid client has additional medical coverage (other than Medicare), it is often referred to as third party liability or TPL. In most cases, providers must bill other insurance carriers before billing Medicaid. Providers are required to notify their clients that any funds the client receives from third party payers (when the services were billed to Medicaid) must be turned over to the Department. The following words printed on the client s statement will fulfill this obligation, When services are covered by Medicaid and another source, any payment the client receives from the other source must be turned over to Medicaid. Exceptions to billing third party first When a Medicaid client is also covered by Indian Health Services (IHS), providers must bill Medicaid first. IHS is not considered a third party liability. If the third party has only potential liability, such as automobile insurance, the provider may bill Medicaid first. Do not indicate the potential third party on the claim. Instead, notify the Department of the potential third party by sending notification to the Third Party Liability Unit (see Key Contacts). 3.2 Coordination of Benefits

21 Hospice Care Services Original Page, July 2004 Requesting an Exemption Providers may request to bill Medicaid first under certain circumstances. In each of these cases, the claim and required information should be sent directly to the Third Party Liability Unit (see Key Contacts). When a provider is unable to obtain a valid assignment of benefits, the provider should submit the claim with documentation that the provider attempted to obtain assignment and certification that the attempt was unsuccessful. When the provider has billed the third party insurance and has received a non-specific denial (e.g., no client name, date of service, amount billed), submit the claim with a copy of the denial and a letter of explanation. If another insurance has been billed, and 90 days have passed with no response, submit the claim with a note explaining that the insurance company has been billed (or a copy of the letter sent to the insurance company). Include the date the claim was submitted to the insurance company and certification that there has been no response. When the Third Party Pays or Denies a Service When a third party payer is involved (excluding Medicare) and the other payer: Pays the claim, indicate the amount paid when submitting the claim to Medicaid for processing. Allows the claim, and the allowed amount went toward client s deductible, include the insurance Explanation of Benefits (EOB) when billing Medicaid. Denies the claim, submit the claim and a copy of the denial (including the reason explanation) to Medicaid. Denies a line on the claim, bill the denied lines together on a separate claim and submit to Medicaid. Include the explanation of benefits (EOB) from the other payer as well as an explanation of the reason for denial (e.g., definition of denial codes). When the Third Party Does Not Respond If another insurance has been billed, and 90 days have passed with no response, bill Medicaid as follows: Submit the claim and a note explaining that the insurance company has been billed (or a copy of the letter sent to the insurance company). Include the date the claim was submitted to the insurance company. Send this information to the ACS Third Party Liability Unit (see Key Contacts). If the provider receives a payment from a third party after the Department has paid the provider, the provider must return the lower of the two payments to the Department within 60 days. Coordination of Benefits 3.3

22 Original Page, July 2004 Hospice Care Services 3.4 Coordination of Benefits

23 Hospice Care Services Original Page, July 2004 Billing Procedures Claim Forms Services provided by the health care professionals covered in this manual must be billed either electronically or on a UB-92 claim form. UB-92 forms are available from various publishing companies; they are not available from the Department or Provider Relations. Timely Filing Limits (ARM ) Providers must submit clean claims to Medicaid within the latest of: Twelve months from whichever is later: the date of service the date retroactive eligibility or disability is determined Medicare Claims: Six months from the date on the Medicare explanation of benefits approving the service (if the Medicare claim was timely filed and the client was eligible for Medicare at the time the Medicare claim was filed). Claims involving other third party payers (excluding Medicare): Six months from the date on an adjustment notice from a third party payer who has previously processed the claim for the same service, and the adjustment notice is dated after the periods described above. Clean claims are claims that can be processed without additional information or action from the provider. The submission date is defined as the date that the claim was received by the Department or the claims processing contractor. All problems with claims must be resolved within this 12 month period. Tips to avoid timely filing denials Correct and resubmit denied claims promptly (see the Remittance Advices and Adjustments chapter in this manual). If a claim submitted to Medicaid does not appear on the remittance advice within 30 days, contact Provider Relations for claim status (see Key Contacts). If another insurer has been billed and 90 days have passed with no response, you can bill Medicaid (see the Coordination of Benefits chapter in this manual for more information). To meet timely filing requirements for Medicare/Medicaid crossover claims, see the Coordination of Benefits chapter in this manual. Billing Procedures 4.1

24 Original Page, July 2004 Hospice Care Services When To Bill Medicaid Clients (ARM ) In most circumstances, providers may not bill Medicaid clients for services covered under Medicaid. If a provider bills Medicaid and the claim is denied because the client is not eligible, the provider may bill the client directly. More specifically, providers cannot bill clients directly: For the difference between charges and the amount Medicaid paid. When the provider bills Medicaid for a covered service, and Medicaid denies the claim because of billing errors. When a third-party payer does not respond. When services are provided by a hospice volunteer physician. Medicaid may not be billed for those services either. Client Cost Sharing Hospice clients are exempt from Medicaid cost sharing. Providers may not charge for cost sharing on any services provided to the hospice client. When Clients Have Other Insurance If a Medicaid client is also covered by Medicare, has other insurance, or some other third party is responsible for the cost of the client s health care, see the Coordination of Benefits chapter in this manual. Billing for Retroactively Eligible Clients When a client becomes retroactively eligible for Medicaid, the provider has 12 months from the date retroactive eligibility was determined to bill for those services. When submitting claims for retroactively eligible clients, attach a copy of the FA-455 (Eligibility determination letter) to the claim if the date of service is more than 12 months earlier than the date the claim is submitted. For more information on retroactive eligibility, see the Client Eligibility and Responsibilities chapter in the General Information For Providers manual. Using the Medicaid Fee Schedule When billing Medicaid, it is important to use the Department s fee schedule for your provider type. The hospice fee schedule is updated each October. Current fee schedules are available on the Provider Information web site (see Key Contacts). For disk or hardcopy, contact Provider Relations (see Key Contacts). Coding Hospice services are billed with five revenue codes and various ICD-9-CM diagnosis codes. The following suggestions may help reduce coding errors and unnecessary claim denials: 4.2 Billing Procedures

25 Hospice Care Services Original Page, July 2004 Use current ICD-9-CM coding books. Always read the complete description and guidelines in the coding books. Relying on short descriptions can result in inappropriate billing. Attend classes on coding offered by certified coding specialists. Billing For Hospice Services Medicaid pays the hospice for each day a client is under hospice care. The payment amounts, limits, and cap amounts are the same as in the Medicare program. The daily rate paid to hospices covers all services normally paid for by Medicare. Rates are set for routine home care, inpatient respite care, general in inpatient care, and continuous home care. Providers must bill for only one of these four fixed daily rates established by Medicare that include all services except for certain physician services and room and board for clients living in a long-term care facility. Please refer to the hospice fee schedule located on the Provider Information web site or available from Provider Relations (see Key Contacts). Routine home care day This is a day in which the client is at home and is not receiving continuous home care during a crisis and is billed per day. Continuous home care This is a day in which the client receives nursing services, home health, or homemaker services on a continuous basis during a period of crisis (see Definitions). The hospice must provide at least eight hours of nursing care per 24 hour period, which does not have to be continuous. Continuous care is billed using the hourly rate for the hours of service provided. Inpatient respite day This is a day in which the client receives inpatient care for respite. The hospice can bill for up to five consecutive days beginning with the day of admission, but excluding the day of discharge. Any respite care days beyond the five consecutive covered days must be billed as routine home care days. General inpatient day This is a day in which the client receives general inpatient care in a hospital for control of pain or management of acute or chronic symptoms that can t be managed in the home. The hospice may bill for the date of admission, but not the date of discharge unless the client is discharged deceased. Always refer to the long descriptions in coding books. The Department will not pay a hospice for inpatient days (general and respite) that exceed 20% of the total hospice care days provided to a client. Billing Procedures 4.3

26 Original Page, July 2004 Hospice Care Services Board and room for nursing facility residents For clients who reside in a nursing facility, the payment rate of the hospice board and room in a nursing facility is the Medicaid rate for that facility, less the client s personal resources applied to the cost of the room and board (and applicable disregards) as determined by the local Office of Public Assistance. This payment replaces the regular Medicaid payment for long-term care while the person receives hospice care. The hospice must instruct the nursing facility to bill the hospice rather than Medicaid. The hospice bills Medicaid and pays the nursing facility for these services. Billing For Physician Services The client s attending physician, whether employed by the hospice or not, may be paid separately. These payment amounts are not included in the hospice cap amount. Payment for these services is the Medicaid rate for physician services. Physicians must use the Physician Related Services manual when billing Medicaid. Manuals are available on the Provider Information web site or from Provider Relations (see Key Contacts). Hospice Cap The hospice may be paid for up to the current established Medicare cap amount on hospice care for a client. Hospice physician services are included in the cap amount. Room and board payments to a long-term care facility and certain payments to the client s attending physician (according to Medicare criteria) are not considered when the cap amount is calculated. The Most Common Billing Errors and How to Avoid Them Paper claims are often returned to the provider before they can be processed, and many others are denied. To avoid returns and denials, double check each claim form to confirm the following items are included and accurate. Reasons for Return Medicaid provider number missing or invalid Authorized signature missing Signature date missing Incorrect claim form used Common Billing Errors How to Prevent Returned Claims The provider number is a 7-digit number assigned to the provider during Medicaid enrollment. Verify the correct Medicaid provider number is on the billing form. Each claim form must have an authorized signature belonging to the provider, billing clerks, or office personnel. The signature may be typed, stamped, computer generated, or hand-written. Each form must have a signature date. Hospice services are billed either electronically or on a UB- 92 claim form. 4.4 Billing Procedures

27 Hospice Care Services Original Page, July 2004 Common Billing Errors (continued) Reasons for Return How to Prevent Returned Claims Information on claim form not legible Recipient number not on file, or recipient was not eligible on date of service Duplicate claim TPL on file and no credit amount on claim Claim past 365-day filing limit Missing Medicare EOMB Provider is not eligible during dates of services, or provider number terminated Information on the claim form should be legible. Use dark ink and center the information in the field information should not be obscured by lines. Before providing services to the client, verify client eligibility by using one of the methods described in the General Information For Providers manual, Client Eligibility and Responsibilities chapter. Please check all remittance advices for previously submitted claims before resubmitting. When making changes to previously paid claims, submit an adjustment form rather than a new claim form (see Remittance Advices and Adjustments). If the client has any other insurance (or Medicare), bill the other carrier before Medicaid, or the claim must be certified by the provider (see the Coordination of Benefits chapter in this manual). If the client s TPL coverage has changed, providers must notify the TPL unit (see Key Contacts) before submitting a claim. The Claims Processing Unit must receive all clean claims and adjustments within the timely filing limits described in the Billing Procedures chapter. To ensure timely processing, paper claims and adjustments should be mailed to Claims Processing at the address shown in Key Contacts. When Medicare is involved in payment on a claim, it must have an EOMB attached or be certified by the provider (see the Coordination of Benefits chapter in this manual). Out-of-state providers must update enrollment early to avoid denials. If enrollment has lapsed, claims submitted with a date of service after the expiration date will be denied. New providers cannot bill for services provided before Medicaid enrollment begins. If a provider requests to be terminated from the Medicaid program, claims submitted with a date of service after the termination date will be denied. Type of service/procedure is not allowed for provider type Provider is not allowed to perform the service, or type of service is invalid. Check the Medicaid fee schedule to verify the procedure code is valid for your provider type. Date of service later than date of death Check that both the correct dates of service and number of days were billed Line level date of service missing The date of service must be recorded in FL45 and must fall within the Statement covers period shown in FL6. Billing Procedures 4.5

28 Original Page, July 2004 Hospice Care Services 4.6 Billing Procedures

29 Hospice Care Services Original Page, July 2004 Submitting a Claim Electronic Claims Professional and institutional claims submitted electronically are referred to as ANSI ASC X12N 837 transactions. Providers who submit claims electronically experience fewer errors and quicker payment. Claims may be submitted electronically by the following methods: ACS field software WINASAP ACS makes available this free software, which providers can use to create and submit claims to Montana Medicaid, MHSP, and CHIP (dental and eyeglasses only). It does not support submissions to Medicare or other payers. This software creates an 837 transaction, but does not accept an 835 (electronic RA) transaction back from the Department. The software can be downloaded directly from the ACS EDI Gateway website. For more information on WINASAP 2003, visit the ACS EDI Gateway website, or call the number listed in the Key Contacts section of this manual. ACS clearinghouse. Providers can send claims to the ACS clearinghouse (ACS EDI Gateway) in X format using a dial-up connection. Electronic submitters are required to certify their 837 transactions as HIPAA-compliant before sending their transactions through the ACS clearinghouse. EDIFECS certifies the 837 HIPAA transactions at no cost to the provider. EDIFECS certification is completed through ACS EDI Gateway. For more information on using the ACS clearinghouse, contact ACS EDI Gateway (see Key Contacts). Clearinghouse. Providers can contract with a clearinghouse so that the provider can send the claim to the clearinghouse in whatever format the clearinghouse accepts. The provider s clearinghouse then sends the claim to the ACS clearinghouse in the X format. The provider s clearinghouse also needs to have their 837 transactions certified through EDIFECS before submitting claims to the ACS clearinghouse. EDIFECS certification is completed through ACS EDI Gateway. Providers should be familiar with the Implementation Guides that describe federal rules and regulations and provide instructions on preparing electronic transactions. These guides are available from the Washington Publishing Company (see Key Contacts). Companion Guides are used in conjunction with Implementation Guides and provide Montana-specific information for sending and receiving electronic transactions. They are available on the ACS EDI Gateway website (see Key Contacts). Submitting a Claim 5.1

30 Original Page, July 2004 Hospice Care Services Billing Electronically with Paper Attachments When submitting electronic claims that require additional supporting documentation, the Attachment Control Number field must be populated with an identifier. Identifier formats can be designed by software vendors or clearinghouses, but the preferred method is the provider s Medicaid ID number followed by the client s ID number and the date of service, each separated by a dash: The supporting documentation must be submitted with a paperwork attachment cover sheet (located on the Provider Information website and in Appendix A). The number in the paper Attachment Control Number field must match the number on the cover sheet. For more information on attachment control numbers and submitting electronic claims, see the Companion Guides located on the ACS EDI website (see Key Contacts). Paper Claims Medicaid Provider ID The services described in this manual are billed on UB-92 claim forms. Claims submitted with all of the necessary information are referred to as clean and are usually paid in a timely manner (see the Billing Procedures chapter in this manual). When completing a claim, remember the following: Please use this information together with the UB-92 Reference Manual. All form locators shown in this chapter are required. Providers bill Medicaid for hospice services using the following revenue codes: Code Client ID Number Date of Service (mmddyyyy) Revenue Codes Description 651 Routine Home Care 652 Continuous Home Care 655 Inpatient Respite Care 656 General Inpatient Care 659 Nursing Facility Rate (Hospice Room and Board) 5.2 Submitting a Claim