NON-EMERGENCY MEDICAL TRANSPORTATION TRAINING

Transcription

1 NON-EMERGENCY MEDICAL TRANSPORTATION TRAINING Medicaid Issues for 2004 (Fall Issue) LOUISIANA MEDICAID PROGRAM DEPARTMENT OF HEALTH AND HOSPITALS BUREAU OF HEALTH SERVICES FINANCING UNISYS

2 ABOUT THIS DOCUMENT This document has been produced at the direction of the Louisiana Department of Health and Hospitals (DHH), Bureau of Health Services Financing (BHSF), the agency that establishes all policy regarding Louisiana Medicaid. DHH contracts with a fiscal intermediary, currently Unisys Corporation, to administer certain aspects of Louisiana Medicaid according to policy, procedures, and guidelines established by DHH. This includes payment of Medicaid claims; processing of certain financial transactions; utilization review of provider claim submissions and payments; processing of pre-certification and prior authorization requests; and assisting providers in understanding Medicaid policy and procedure and correctly filing claims to obtain reimbursement. This training packet has been developed for presentation at the 2004 Louisiana Medicaid Provider Training workshops. Each year these workshops are held to inform providers of recent changes that affect Louisiana Medicaid billing and reimbursement. In addition, established policies and procedures that prompt significant provider inquiry or billing difficulty may be clarified by workshop presenters. The emphasis in the workshops is on policy and procedures, which affect Medicaid billing. This packet does not present general Medicaid policy such as standards for participation, recipient eligibility and ID cards, and third party liability. Such information is presented only in the Basic Medicaid Information Training packet. The Basic Medicaid Information Training packet may be obtained by attending a Basic Medicaid Information workshop or by requesting a copy from Unisys Provider Relations or by download from the LAMEDICAID website. Providers should use this packet in conjunction with the Louisiana Medicaid NEMT provider manual.

3 FOR YOUR INFORMATION! SPECIAL MEDICAID BENEFITS FOR CHILDREN AND YOUTH I. MR/DD WAIVER WAITING LIST The MR/DD Waiver Program provides services in the home, instead of institutional care, to persons who are mentally retarded or have other developmental disabilities. Each person admitted to the Waiver Program occupies a "slot." Slots are filled on a first-come, first-served basis. Services provided under the MR/DD Waiver are different from those provided to Medicaid recipients who do not have a Waiver slot. Some of the services that are only available through the Waiver are: Respite Services; Substitute Family Care Services; Supervised Independent Living and Habilitation/Supported Employment. There is currently a Waiting List for waiver slots. TO ADD YOUR NAME TO THE WAITING LIST FOR MR/DD WAIVER SERVICES, CALL THIS TOLL-FREE NUMBER: II. BENEFITS FOR CHILDREN AND YOUTH ON THE MR/DD WAIVER WAITING LIST CASE MANAGEMENT If you are a Medicaid recipient under the age of 21 and have been on the MR/DD Waiver Waiting list at any time since October 20, 1997, you may be eligible to receive case management NOW. YOU NO LONGER NEED TO WAIT FOR THIS SERVICE. A case manager works with you to develop a comprehensive list of all needed services (such as medical care, therapies, personal care services, equipment, social services, and educational services), then assists you in obtaining them. TO ADD YOUR NAME TO THE WAITING LIST FOR MR/DD WAIVER SERVICES, CALL THIS TOLL-FREE NUMBER: Louisiana Medicaid NEMT Provider Training Notice P-17 Revised November 1, 2000 ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

4 III. BENEFITS AVAILABLE TO ALL CHILDREN AND YOUTH UNDER THE AGE OF 21 THE FOLLOWING SERVICES ARE AVAILABLE NOW. YOU DO NOT NEED TO WAIT FOR A WAIVER SLOT TO OBTAIN THEM. EPSDT/KIDMED EXAMS AND CHECKUPS Medicaid recipients under the age of 21 are eligible for checkups ("EPSDT screens"). These checkups include a health history, physical exam, immunizations, vision and hearing checks, and dental services. They are available both on a regular basis, and whenever additional health treatment or services are needed. TO OBTAIN AN EPSDT SCREEN OR DENTAL SERVICES CALL KIDMED (TOLL FREE) at (or TTY ). EPSDT screens may help to find problems which need other health treatment or additional services. Children under 21 are entitled to receive all necessary health care, diagnostic services, and treatment and other measures covered by Medicaid to correct or improve physical or mental conditions. This includes a wide range of services not normally covered by Medicaid for recipients over the age of 21. Some of these additional services are very similar to services provided under the MR/DD Waiver Program. There is no waiting list for these Medicaid services. PERSONAL CARE SERVICES Personal care services are provided by attendants to persons who are unable to care for themselves. These services assist in bathing, dressing, feeding, and other non-medical activities of daily living. PCS services do not include medical tasks such as medication administration, tracheostomy care, feeding tubes or catheters. The Medicaid Home Health program or Extended Home Health program covers those medical services. PCS services must be ordered by a physician. Once ordered by a physician, the PCS service provider must request approval for the service from Medicaid. FOR ASSISTANCE IN APPLYING FOR THIS SERVICE AND LOCATING A PCS SERVICE PROVIDER CALL KIDMED (TOLL FREE) at (or TTY ). EXTENDED HOME HEALTH SERVICES Children and youth may be eligible to receive Skilled Nursing Services and Aide Visits in the home. These can exceed the normal hours of service and types of service available for adults. These services are provided by a Home Health Agency and must be provided in the home. This service must also be ordered by a physician. Once ordered by a physician, the home health agency must request approval for the service from Medicaid. FOR ASSISTANCE IN APPLYING FOR THIS SERVICE AND LOCATING A HOME HEALTH SERVICE PROVIDER CALL KIDMED (TOLL FREE) at (or TTY ) Louisiana Medicaid NEMT Provider Training Notice P-17 Revised November 1, 2000 ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

5 PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY, AND AUDIOLOGY SERVICES If a child or youth wants Rehabilitation Services such as Physical, Occupational, or Speech Therapy, or Audiology Services outside of or in addition to those being provided in the school, these services can be provided by Medicaid at hospitals on an outpatient basis, or, in the home from Rehabilitation Centers or under the Home Health program. These services must also be ordered by a physician. Once ordered by a physician, the service provider must request approval for the service from Medicaid. FOR ASSISTANCE IN APPLYING FOR THESES SERVICES AND LOCATING A SERVICE PROVIDER CALL KIDMED (TOLL FREE) at (or TTY ). SERVICES IN SCHOOLS OR EARLY INTERVENTION CENTERS Children and youth can also obtain Physical, Occupational, and Speech Therapy, Audiology Services, and Psychological Evaluations and Treatment through early intervention centers (for ages 0-2) or through their schools (For ages 3-21). Medicaid covers these services if the services are a part of the IFSP or IEP. These services may also be provided in the home. FOR INFORMATION ON RECEIVING THESE THERAPIES CONTACT YOUR EARLY INTERVENTION CENTER OR SCHOOL OR CALL KIDMED (TOLL FREE) at (or TTY ). MEDICAL EQUIPMENT AND SUPPLIES Children and youth can obtain any medically necessary medical supplies, equipment and appliances needed to correct, improve, or assist in dealing with physical or mental conditions. Medical Equipment and Supplies must be ordered by a physician. Once ordered by a physician, the supplier of the equipment or supplies must request approval for them from Medicaid. FOR ASSISTANCE IN APPLYING FOR MEDICAL EQUIPMENT AND SUPPLIES AND LOCATING MEDICAL EQUIPMENT PROVIDERS CALL KIDMED (TOLL FREE) at (or TTY ). MENTAL HEALTH REHABILITATION SERVICES Children or youth with mental illness may receive Mental Health Rehabilitation Services. These services include: clinical and medical management; individual and parent/family intervention; supportive and group counseling; individual and group psychosocial skills training; behavior intervention plan development and service integration. MENTAL HEALTH REHABILITATION SERVICES MUST BE APPROVED BY THE LOCAL OFFICE OF MENTAL HEALTH. FOR ASSISTANCE IN APPLYING FOR MENTAL HEALTH REHABILITATION SERVICES CALL KIDMED (TOLL FREE) at (or TTY ). TRANSPORTATION Transportation to and from medical appointments, if needed, is provided by Medicaid. These medical appointments do not have to be with Medicaid providers for the transportation to be covered. Arrangements for non-emergency transportation must be made at least 48 hours before the scheduled appointment. TO ARRANGE MEDICAID TRANSPORTATION CALL KIDMED (TOLL FREE) at (or TTY ) Louisiana Medicaid NEMT Provider Training Notice P-17 Revised November 1, 2000 ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

6 OTHER MEDICAID COVERED SERVICES Ambulatory Care Services, Rural Health Clinics, and Federally Qualified Health Centers Ambulatory Surgery Services Certified Family and Pediatric Nurse Practitioner Services Chiropractic Services Developmental and Behavioral Clinic Services Diagnostic Services-laboratory and X-ray Early Intervention Services Emergency Ambulance Services Family Planning Services Hospital Services-inpatient and outpatient Nursing Facility Services Nurse Midwifery Services Podiatry Services Prenatal Care Services Prescription and Pharmacy Services Health Services Sexually Transmitted Disease Screening MEDICAID RECIPIENTS UNDER THE AGE OF 21 ARE ENTITLED TO RECEIVE THE ABOVE SERVICES AND ANY OTHER NECESSARY HEALTH CARE, DIAGNOSTIC SERVICE, TREATMENT AND OTHER MEASURES COVERED BY MEDICAID TO CORRECT OR IMPROVE A PHYSICAL OR MENTAL CONDITION. This may include services not specifically listed above. These services must be ordered by a physician and sent to Medicaid by the provider of the service for approval. If you need a service that is not listed above call KIDMED (TOLL FREE) at (or TTY ). If you do not RECEIVE the help YOU need ask for the referral assistance coordinator Louisiana Medicaid NEMT Provider Training Notice P-17 Revised November 1, 2000 ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

7 NOTICE TO ALL PROVIDERS Pursuant to Chisholm v. Cerise DHH is required to inform both recipients and providers of certain services covered by Medicaid. The following two pages contain notices that are sent by DHH to some Medicaid recipients notifying them of the availability of services for EPSDT recipients (recipients under age 21). These notices are being included in this training packet so that providers will be informed and can help outreach and educate the Medicaid population. Please keep this information readily available so that you may provide it to recipients when necessary. DHH reminds providers of the following services available for all recipients under age 21: Children under age 21 are entitled to receive all necessary health care, diagnostic services, and treatment and other measures covered by Medicaid to correct or improve physical or mental conditions. This includes a wide range of services not normally covered by Medicaid for recipients over the age of 21. Whenever health treatment or additional services are needed, you may obtain an appointment for a screening visit by contacting KIDMED. Such screening visits also can be recommended by any health, developmental, or educational professional. To schedule a screening visit, contact KIDMED at (toll-free) (or , if you live in the Baton Rouge area), or by contacting your physician if you already have a KIDMED provider. If you are deaf or hard of hearing, please call the TTY number, (tollfree) If you have a communication disability or are non-english speaking, you may have someone else call KIDMED and the appropriate assistance can be provided. Transportation to and from medical appointments, if needed, is provided by Medicaid. These medical appointments do not have to be with Medicaid providers for the transportation to be covered. Arrangements for non-emergency transportation must be made at least 48 hours before the scheduled appointment. TO ARRANGE MEDICAID TRANSPORTATION CALL KIDMED (TOLL FREE) at (or TTY ). Recipients may also CALL KIDMED (TOLL FREE) at (or TTY ) for referral assistance with all services, not just transportation Louisiana Medicaid NEMT Training ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

8 Services Available to Medicaid Eligible Children Under 21 If you are a Medicaid recipient under the age of 21, you may be eligible for the following services: *Doctor s Visits *Hospital (inpatient and outpatient) Services *Lab and X-ray Tests *Family Planning *Home Health Care *Dental Care *Rehabilitation Services *Prescription Drugs *Medical Equipment, Appliances and Supplies (DME) *Case Management *Speech and Language Evaluations and Therapies *Occupational Therapy *Physical Therapy *Psychological Evaluations and Therapy *Psychological and Behavior Services *Podiatry Services *Optometrist Services *Hospice Services *Extended Skilled Nurse Services *Residential Institutional Care or Home and Community Based (Waiver) Services *Medical, Dental, Vision and Hearing Screenings, Periodic and Interperiodic *Prenatal Care *Immunizations *Eyeglasses *Hearing Aids *Psychiatric Hospital Care *Personal Care Services *Audiological Services *Necessary Transportation: Ambulance Transportation, Non-ambulance Transportation *Appointment Scheduling Assistance *Substance Abuse Clinic Services *Chiropractic Services *Certified Nurse Practitioners *Certified Nurse Midwives *Mental Health Clinic Services *Mental Health Rehabilitation and any other medically necessary health care, diagnostic services, treatment, and other measures which are coverable by Medicaid, which includes a wide range of services not covered for recipients over the age of 21. *** You may access other services by calling KIDMED at (toll-free) If you are deaf or hard of hearing, please call the TTY number, (toll-free) If you have a communication disability or are non-english speaking, you may have someone else call KIDMED and the appropriate assistance can be provided. Some of these services must be approved by Medicaid in advance. Your medical provider should be aware of which services must be pre-approved and can assist you in obtaining those services. Also, KIDMED can assist you or your medical provider with information as to which services must be pre-approved Louisiana Medicaid NEMT Training ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

9 Whenever health treatment or additional services are needed, you may obtain an appointment for a screening visit by contacting KIDMED. Such screening visits also can be recommended by any health, developmental, or educational professional. To schedule a screening visit, contact KIDMED at (toll-free) (or , if you live in the Baton Rouge area), or by contacting your physician if you already have a KIDMED provider. If you are deaf or hard of hearing, please call the TTY number, (toll-free) If you have a communication disability or are non-english speaking, you may have someone else call KIDMED and the appropriate assistance can be provided. Louisiana Medicaid encourages you to contact the KIDMED office and obtain a KIDMED provider so that you may be better served. If you live in a CommunityCARE parish, please contact your primary care physician for assistance in obtaining any of these services or contact KIDMED at (toll-free) Louisiana Medicaid NEMT Training ***DISCLAIMER: This information is currently being updated and some content may be incorrect or incomplete. If you are unable to get assistance using the telephone numbers listed under the specific programs, you may contact Medicaid Program Operations at

10 TABLE OF CONTENTS SECTION PAGE Electronic Data Interchange...1 Policy Reminders...4 Timeliness...4 Efficient Trip Scheduling...4 Recipient Freedom Of Choice...4 Canceled Trips/Dry Runs...4 Provider Service Area...5 Policy Clarification...5 Minimum Liability Insurance Requirements...5 Attendents/Children...6 Reimbursement...7 Intra-State Rates...8 Documentation...9 Daily Schedule Of Transports...9 Form Mt-3 And Instructions For Completion...10 Reminders To Providers...11 Form Mt-3 (Example Form)...12 Form Mt-3 (Blank Form) Statewide Dispatch Service...14 Claims Filing...15 Instructions On Completing Unisys Form Form 106 (Example Form)...18 Form 106 (Blank Form) Instructions On Completing Unisys Form Form 206 (Example Form)...21 Form 206 (Blank Form) Frequently Asked Questions...23 Claim Denials And Resolution...24 General Claim Form Completion Error Codes...24 Recipient Eligibility Error Codes...25 Timely Filing Error Codes...25 Duplicate Claim Error Code...26 Prior Authorization Error Codes...26 Hardcopy Claim Requirements...28 Louisiana Medicaid Website Applications...29 Provider Assistance...32 Telephone Inquiry Unit...32 Correspondence Unit...33 Field Analysts...33 Additional Numbers For Provider Assistance...35 BHSF Regional Transportation Inspectors...36 EDI Claims Submission...37 Claims Filing Addresses...40 Claims Processing Reminders Louisiana Medicaid NEMT Provider Training i

11 ELECTRONIC DATA INTERCHANGE It is very important for providers billing electronically to take the necessary steps to ensure that their claims are submitted using the HIPAA mandated 837 specifications. The following information will assist your Software Vendor, Billing Agent or Clearinghouse (VBC) to submit HIPAA approved 837 transactions to Louisiana Medicaid. The following table contains the current DHH implementation schedule for transition to HIPAA compliant electronic submissions by the applicable Medicaid Programs. Affected providers will be required to bill Louisiana Medicaid using the compliant 837 format by the implementation date stated below. Additionally, in the near future claims submitted using the proprietary specifications will be held for 21 days. Please watch for further information that will be forthcoming about this change. PROGRAM IMPLEMENTATION DATE Ambulance Transportation January 1, 2005 DME January 1, 2005 Dental January 1, 2005 Hemodialysis November 1, 2004 Hospice November 1, 2004 Hospital Inpatient/Outpatient November 1, 2004 KIDMED TBD Personal Care Services (PCS) Professional: Ambulatory Surgical Centers EPSDT Health Services Independent Lab & X-ray Mental Health Clinics Mental Health Rehabilitation Centers Physician Services (including physicians, optometrists, podiatrists, audiologists, psychologists, chiropractors, APRNs) Rehabilitation Centers Vision Rural Health Clinics/Federally Qualified Health Centers Waiver (all) TBD To Be Phased In Beginning April 1, 2005 (Further information concerning dates of phases and programs will be forthcoming.) TBD TBD NOTE 1: Long Term Care/LTC (Nursing Facilities, ICF-MR Facilities, Hospice Room and Board, Adult Day Health Care Facilities) MUST ultimately transition to either 837 electronic billing or UB-92 paper billing. The final implementation date for this transition is to be determined. NOTE 2: Non-Emergency Medical Transportation and Case Management Providers are excluded from HIPAA and will continue to submit electronic claims with the Louisiana Medicaid Proprietary Transactions Louisiana Medicaid NEMT Provider Training 1

12 If you are not currently submitting the HIPAA compliant 837 transaction, Louisiana Medicaid strongly recommends that you contact your VBC to determine if they can meet your needs as a Louisiana Medicaid provider. If your VBC has not started testing, you may go to to view the VBC list and select a VBC that is approved for your program. This list is updated monthly by the EDI group. YOU MUST BE TRANSITIONED TO THE 837 HIPAA COMPLIANT FORMAT BY THE APPLICABLE DATES IN ORDER TO CONTINUE TO SUBMIT CLAIMS ELECTRONICALLY. The list includes contact information, the types of X12N HIPAA 837 transactions supported, and a status of Enrolled, Testing, Parallel, or Approved. The final Approved status means a provider can submit HIPAA EDI 837 transactions THROUGH the approved VBC to Louisiana Medicaid. Louisiana Medicaid encourages all providers to use the VBC list to shop for a VBC that best suits their needs and budget. The features, functions, and costs vary significantly between VBCs. Find the one that is right for you. Providers can also monitor the list to see how their VBC is progressing toward production approval. HIPAA DESK TESTING SERVICE ENROLLMENT The first step towards HIPAA readiness is to have the VBC complete the HIPAA Testing Enrollment Form located at All VBCs MUST complete the required testing before any electronic claims may be submitted for providers. Therefore, the VBC must contact the LA Medicaid HIPAA EDI Group to enroll. (Providers who develop their own electronic means of submitting claims to LA Medicaid are considered the VBC). VBCs can also get an enrollment form by ing the HIPAA EDI group at *hipaaedi@unisys.com or by calling (225) The VBC must complete the form and return it by to Louisiana Medicaid. A HIPAA EDI representative will issue the VBC login information for our testing service. Throughout the implementation of HIPAA requirements, Louisiana Medicaid has offered intense support. One of the support systems offered to the VBCs is HIPAADesk.com, which is a completely automated testing site for validation of X12 syntax. While the HIPAADesk.com is available for any VBC s use to validate X12 transactions, Louisiana Medicaid has furnished additional resources within this site. The enhanced Louisiana-specific service will be offered through January 31, 2005 only. After that, it will be the responsibility of the VBC to validate X12 syntax before testing with Louisiana Medicaid. Validation of X12 syntax does not validate 837 transactions for submission to Louisiana Medicaid. Additional testing is required. With the exception of Long Term Care providers, individual providers using software that has been approved for a VBC do not need to test individually. Once a VBC is approved for production, this approval is also applied to those providers using the approved software. In the Louisiana-specific section of HIPAADesk.com all Companion Guides for the 837I, 837P, 837D, and 278 transactions are available for download. Our testing service through HIPAADesk.com is available 24 hours a day, 7 days a week and will maintain those hours through the end of January Louisiana Medicaid NEMT Provider Training 2

13 HIPAA-COMPLIANT 837 TRANSACTION TESTING SERVICE Testing of 837 transactions involves two levels: validation of 837 transaction syntax and parallel testing of claims submitted in proprietary and HIPAA-compliant formats. Once the VBC has contacted Louisiana Medicaid and the enrollment process is complete, login information will be furnished to the identified testers on the enrollment form. The testing service is a secure web based application that requires an internet connection and a web browser. The testing service contains all necessary information for a VBC to test for compliance with Louisiana Medicaid. Companion Guides for the 837I, 837P, 837D, and 278 transactions and other necessary and useful documentation are available for download from within the HIPAADesk.com testing service. Each 837 testing program includes several tasks that must be performed successfully to complete EDI Desk.com testing. Upon completion of EDI testing, the VBC will begin MMIS Parallel Testing. The testing service is comprehensive and evaluates SNIP 1-7 types of testing. MMIS PARALLEL TESTING Please refer to the section on Connectivity with the Payer/Communications in the Louisiana Medicaid General Companion Guide for instructions on how to gain access to our test Bulletin Board System (BBS). This guide is also available for download from within HIPAADesk.com. Parallel testing will compare a current proprietary electronic claim file with a parallel HIPAA EDI file both utilizing the same source data. Generally, the current proprietary and HIPAA EDI file should adjudicate the same. NOTE: For those submitters who did not previously send proprietary electronic Medicaid claims, such as TAD billers, the parallel testing process will be slightly different. Instead of sending a copy of an EDI file to the BBS, you will 25 Internal Control Numbers (ICNs) from paper-billed claims from your last remittance advice to your HIPAA EDI QA parallel testing support person. If there weren t 25 ICNs on your last remittance advice, all the ICNs on your most recent weeks remittance advice and that is acceptable. If a tester does not have an assigned support person, contact the HIPAA EDI Test Team at *hipaaedi@unisys.com or call (225) These claims will be compared to the HIPAA file sent to the test BBS, which was generated from the same data Louisiana Medicaid NEMT Provider Training 3

14 POLICY REMINDERS Timeliness Providers are responsible for picking up recipients in a timely manner to insure that they arrive at their appointments on time and are returned home within a reasonable amount of time. If a provider accepts a trip, and then determines that he is unable to provide the service, the provider must notify the dispatch office immediately, provide an explanation, and notify the recipient. If a driver returns to pick up a recipient and cannot locate the recipient, the driver must determine if the recipient left the premises and make every attempt to locate the recipient. If the recipient cannot be located, the driver must notify his office immediately, and the provider must notify the dispatch office immediately. Failure on the part of the driver/provider to act responsibly may result in administrative sanctions, such as suspension from the program. Efficient Trip Scheduling Providers must transport as many recipients as the vehicles allow when there are individuals going to the same medical service during the same time period. However, when transporting recipients whose waiting time is excessive, recipients who are ready to leave should be taken home. The provider should either return later or send another vehicle to pick up recipients who had not completed their appointments. Recipient Freedom Of Choice The recipient is entitled to freedom of choice. A medical provider cannot decide for the recipient which transportation provider will be used. The dispatch office assigns trips based on the least costly means of transportation available in the geographic area, with consideration given to the recipient s preference. Requests for transportation must be made directly to the dispatch office, not to individual transportation providers. Canceled Trips/Dry Runs A provider must be able to receive cancellations between 8:00 a.m. and 4:30 p.m. Monday through Friday. A provider may not file a claim for a trip, which has been canceled, by the dispatch office. No payment is made for a dry run. A dry run occurs when a provider is assigned a trip and the recipient is not at the pick up point, or the recipient canceled the medical appointment. In order for a service to be billed, a recipient must be transported Louisiana Medicaid NEMT Provider Training 4

15 Provider Service Area A provider service area is the parish or parishes in which the transportation provider is authorized to operate. A minimum of one vehicle must be available per parish in the service area. Health Standards approves requests to serve a particular area, as well as expansions or reductions in authorized service areas or changes in a provider s capacity. As part of the approval process, the provider s record keeping and billing activity will be reviewed for accuracy and compliance. Expansions will not be approved for providers requiring corrective action until necessary changes are made. Requests for expansion within 60 days of enrollment (or the last review which revealed no problems) will be granted without another review. The transportation provider must be authorized to transport within the recipient s parish of origin. POLICY CLARIFICATION Minimum Liability Insurance Requirements A provider is required to have minimum liability insurance coverage of $100,000 per person and $300,000 per accident, or a combined single limit of $300,000 at all times. Providers authorized to transport recipients out of state must carry a minimum of $1,500,000 in automobile liability coverage. Automobile liability must include coverage for owned, hired, and non-owned autos. Each provider must be covered at all times by general liability insurance to cover the business entity and maintain a minimum coverage of $300,000 combined single Limit of Liability at all times. Failure to comply with the minimum liability insurance coverage requirements on each vehicle and on the business entity is grounds for immediate suspension as a Medicaid transportation provider. Operation without the minimum liability insurance coverage is a violation of the provider enrollment and participation requirements. All payments made during the period of violation are subject to recoupment. The dispatch office is immediately notified by Health Standards when a provider is suspended for failure to comply with insurance requirements. In accordance with DHH policy, the dispatch office is instructed to immediately cancel trips assigned to the provider, including capitated trips, and to attempt to reschedule the trips. There are situations when the provider fulfills the requirements in a short time and becomes reinstated. If this is the case, and the reinstated provider is informed by dispatch that the trips have already been rescheduled, the dispatch office will not cancel the second provider in order to re-schedule the original provider. This is DHH policy; it is the responsibility of the provider to comply with the insurance requirements. Under no circumstances will the dispatch office schedule a trip with a provider who is out of compliance. Dispatch must receive notification of reinstatement from Health Standards before scheduling can resume Louisiana Medicaid NEMT Provider Training 5

16 Attendants/Children Medicaid does not pay for the transportation of an attendant or accompanying children. The provider may not bill Medicaid, or the recipient, or anyone else for the transport of an attendant or a child. The dispatch office is required to inform the transportation provider if a recipient intends to be accompanied by a child or children. The transportation provider may refuse to transport the child or children, or may refuse to transport more than one child or attendant. The transportation provider may determine that an adult recipient requires an attendant, and may require an attendant to accompany the recipient. The dispatch office is responsible for determining if an attendant is needed for a recipient. A parent, legal guardian, or responsible person must accompany children under the age 17. The attendant MUST: 1. Be age 17 or older; and 2. Be designated by the parent if the attendant is not the parent or legal guardian; and 3. Be able to authorize medical treatment and to care for the child; and 4. Accompany the child to and from the medical appointment. The attendant MUST NOT: 5. Be a Medicaid provider or employee of a Medicaid provider that is providing services to the recipient being transported; or 6. Be a transportation provider or an employee of a transportation provider; or 7. Be an employee of a mental health or substance abuse clinic Louisiana Medicaid NEMT Provider Training 6

17 REIMBURSEMENT Non-profit providers may not receive capitated payments. Only for-profit providers may be reimbursed at capitated rates. Capitated payments are based on the number of trips and the distance traveled. Additional trips for medical appointments related to the service for which the capitated trips are scheduled are included in the capitated rate. A provider who accepts a capitated payment is required to provide transportation for related medical appointments, and no additional payment for these trips may be made. NEMT NON-AMBULANCE RATES AND CODES PROFIT PROVIDERS PROCEDURE CODE RATES Flat Rate Z5177 $ per recipient Negotiated Z5178 To be given by dispatch Capitated (urban) Z5179 $ per month Capitated (rural) Z5180 $ per month Enhanced Capitated Z5182 $ per month (5 trips or more per week) Remote Capitated Z5183 $ per month (>120 miles round trip) Wheelchair Capitated (rural) Z5184 $ per month Wheelchair Capitated (urban) Z5185 $ per month Wheelchair local Z5186 $ per recipient Capitated-Negotiated Z5188 Determined by state office NON-PROFIT PROVIDERS PROCEDURE CODE RATES Flat Rate Z9498 $ per trip Negotiated Z5176 To be given by dispatch Wheelchair local Z5187 $ per recipient Please Note: These rates and codes are effective for dates of service August 1, 2003, however rates and codes are subject to change. A provider, who accepts a capitated rate to transport a recipient to a series of medical appointments, must be available on each day an appointment is scheduled. For example, if a recipient needs transportation to and from a dialysis center on Tuesday, Thursday, and Saturday, transportation must be provided on all three days. A provider may not choose the days he/she is available to transport the recipient to the center. Also, the transportation provider must transport the recipient to and from the appointments unless otherwise specified by the recipient Louisiana Medicaid NEMT Provider Training 7

18 NEMT INTRA-STATE RATES (based on round trip mileage) MILES RATE 0-65 $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Louisiana Medicaid NEMT Provider Training 8

19 DOCUMENTATION A provider must maintain sufficient documentation to identify that recipients were transported. Such documentation consists of points of origin and destinations, driver qualifications, vehicle capabilities, and safety. Documentation must be maintained for five (5) years from the date on which the claim is paid. Daily Schedule Of Transports A provider must maintain a daily schedule of transports by parish of origin. The schedules must be available for review of trips by parish and by date. The schedule must include the recipient s name, address (or point of origin), appointment time, assigned driver(s), assigned vehicle(s), and destination Louisiana Medicaid NEMT Provider Training 9

20 Form MT-3 And Instructions For Completion The MT-3 provides verification that a medical appointment was kept. It is completed by the driver and signed by the recipient and the medical provider or representative to confirm that the trip was completed. If the recipient does not or will not sign the MT-3, an explanation must be given in the remarks section of the claim form (Form 106). Following are instructions for completion of the Form MT-3 and a sample MT-3 form. Top Section of MT-3 Form: Date of Transportation: complete space provided with the date the transportation is being provided. Time of Appointment: complete space provided with the actual time of the medical appointment. Circle a.m. or p.m. as appropriate. I. Recipient Verification of Medical Transportation Transportation Provider Name: complete with provider s name. Recipient s Name: complete with recipient s name as it appears on the medical eligibility card. Recipient s ID #: complete with the recipient s 13-digit ID number. Recipient s Address: complete with the recipient s complete address including zip code. Signature and Date: the recipient must sign and date with that day s date. If the recipient signs with a mark, this mark must be witnessed by at least one person who can sign his/her name. II. Driver Certification The driver of the vehicle should sign and date the form, providing the name of the driver who picked up the recipient for the appointment and returned the recipient after the appointment. III. Medical Service Provider Verification The medical provider or his/her representative must complete section III. If the recipient did not receive medical services, an explanation is required. An office stamp is accepted, but the medical provider or his/her representative must also sign and give his/her title and date. The MT-3 form may not be signed prior to the service being rendered. The form should be returned to the transportation provider. Further information on the use of this form can be found in Section 7 of the Medicaid Transportation Services provider manual (issued January 20, 1998) Louisiana Medicaid NEMT Provider Training 10

21 Reminders To NEMT Providers All fields on the Form MT-3 MUST be completed. Form MT-3 is to be signed on the day of transport. Neither the NEMT provider nor the Medical Service Provider should pre date the form. All services for recipients are to be Prior Authorized. Recipients should not be transported without a Form MT-3. MT-3 forms submitted to Medical Dispatch AFTER transport will be denied. Weekend/after hour s transports must have verbal authorization by paging Medical Dispatch. Providers refusing transports must fax the Prior Authorization request back to Medical Dispatch immediately so recipients can be rescheduled Louisiana Medicaid NEMT Provider Training 11

22 XYZ MEDICAL INC :00 FAITH MAEBELL NOW DR. HAPPY, LA Faith Maebell 8/28/04 JR Walker 8/28/04 JR Walker 8/28/ :00 Do Right, MD 8/28/ Louisiana Medicaid NEMT Provider Training 12

23 2004 Louisiana Medicaid NEMT Provider Training 13

24 STATEWIDE DISPATCH SERVICE REGIONAL TRANSPORTATION DISPATCH OFFICES Toll Free Numbers Region Parishes Phone Fax 1-New Orleans 2-Baton Rouge 3-Lafayette 4-Lake Charles 5-Alexandria 6-Shreveport 7-Monroe Orleans East Jefferson Plaquemines St. Bernard Ascension Assumption East Baton Rouge East Feliciana Iberville Lafourche Livingston Pointe Coupee Acadia Evangeline Iberia Lafayette Allen Beauregard Calcasieu Avoyelles Catahoula Concordia Grant Bienville Bossier Caddo Claiborne DeSoto Caldwell East Carroll Franklin Jackson Lincoln Madison St. Charles St. James St. John West Jefferson St. Helena St. Tammany Tangipahoa Terrebonne West Baton Rouge Washington W. Feliciana St. Martin St. Mary Vermilion St. Landry Cameron Jefferson Davis LaSalle Rapides Vernon Winn Natchitoches Red River Sabine Webster Ouachita Richland Tensas Union West Carroll Morehouse Provider Line: (866) Provider Line: (866) Provider Line: (866) Provider Line: (866) Provider Line: (866) Provider Line: (866) Provider Line: (866) (800) (800) (800) (800) (800) (800) (800) Louisiana Medicaid NEMT Provider Training 14

25 CLAIMS FILING Non-Emergency Medical Transportation claims are filed on the Unisys Form 106. Completed claims should be mailed to: Unisys P. O. Box Baton Rouge, LA Normal, clean claims that go to the claims post office boxes should take no more than 30 calendar days from the date Unisys receives the claims to complete processing. Of course, claims that must pend will take longer to be paid. Nonetheless, these will appear in the provider s claims in processing RA section within the 30-day timeframe. Voids are filed on the Unisys Form 206. Non Emergency, Non-Ambulance medical transportation claims cannot be adjusted, only voided. If a claim was paid incorrectly, the payment must first be voided and then a correct 106 Form should be submitted to Unisys for payment consideration. Completed 206 forms should be mailed to the above address. The following pages give the billing instructions for completing the 106 Form and the 206 Form. Also included are blank form copies and examples of a correctly completed Unisys 106 Form and 206 Form Louisiana Medicaid NEMT Provider Training 15

26 INSTRUCTIONS ON COMPLETING UNISYS FORM Enter recipient s last name. 2. Enter recipient s first name. 3. Enter recipient s middle initial. 4. Enter the 13-digit Medicaid Identification number of the recipient. This information can be accessed by utilizing REVS, MEVS or e-mevs. 5. Enter the recipient s address. 6. Enter the recipient s date of birth. 7. Enter the recipient s sex. 8. Enter the time, month, day, and year of the recipient s medical appointment. 9. Enter the origin of service. 10. Enter the destination of service. 11. Enter the 10-digit alphanumeric prior authorization number assigned by the dispatch office. 12. Check the appropriate block to indicate whether the scheduled service was one-way or two-way transport. 13. Leave blank. 14. This item serves as a reminder that all non-emergency medical transportation must be prior authorized by the dispatch office. 15. Leave blank. 16. Enter the name and address of the transportation provider providing the service. 17. Enter the provider s 7-digit Medicaid number. 18. Enter the name of the medical provider. 19. If applicable, enter the recipient s medical record number assigned by the medical service provider. 20. Leave blank. 21A. Enter the date the transportation service was rendered. 21B. Enter the correct origin code from those listed on the form to show where the trip began. 21C. Enter the correct destination code from those listed on the form to show where the trip ended Louisiana Medicaid NEMT Provider Training 16

27 21D. Enter the five-digit procedure code prior authorized by the dispatch office. Only one trip may be billed per claim form. 21E. Leave blank. 21F. Enter the monetary charge for the procedure code. 21G. Leave blank. 22. The provider or the provider s representative must sign and date the claim form. Stamped or computer-generated signatures will be accepted only if they are initialed by the provider or the provider s representative. Note: The remarks section should be used to explain any unusual occurrences (i.e., the recipient or the medical provider refused to sign the MT-3 form) Louisiana Medicaid NEMT Provider Training 17

28 Faith Maebell X 345 Now Drive Maebell Faith 345 Now Drive Happy, LA LL Dr. Do. Right 777 Do Right City of Gold, LA X XYZ Medical Inc. 602 Yes Lane City of Gold, LA Dr. Do Right Z J.RIDDLE 8/31/ Louisiana Medicaid NEMT Provider Training 18

29 2004 Louisiana Medicaid NEMT Provider Training 19

30 INSTRUCTIONS ON COMPLETING UNISYS FORM 206 Non-Emergency, Non-Ambulance medical transportation claims may only be voided.. Only a paid claim can be voided. Providers submit their voids on the 206 form, which can be obtained by contacting Unisys Provider Relations. This form must be completed EXACTLY as it was filed initially. 1. Check Void box. 2. Enter recipient s last name. 3. Enter recipient s first name. 4. Enter recipient s middle initial. 5. Enter the 13-digit Medicaid Identification number of the recipient. 6. Enter the recipient s address. 7. Enter the recipient s date of birth. 8. Enter the recipient s sex. 9. Enter the time, month, day, and year of the recipient s medical appointment. 10. Enter the origin of service. 11. Enter the destination of service. 12. Enter transport authorization type. 13. Enter EPSDT referral. 14. Enter the name and address of the transportation provider providing the service. 15. Enter the provider s 7-digit Medicaid number. 16. Enter the name of the medical provider. 17. Enter the recipient s medical record number as assigned by the provider. 18. Leave blank. 19 Enter the information exactly as it appeared on the original claim form. 20. Remarks. 21. Enter the control number exactly as it appeared on the RA. 22. Enter the date of the Remittance Advice the claim paid. 23. Leave blank. 24. Check the appropriate box and write a brief narrative explaining the reason. 25. The provider or the provider s representative must sign and date the claim form. 26. Enter the date signed Louisiana Medicaid NEMT Provider Training 20

31 X Faith Maebell Now Drive X 10: Maebell Faith 345 Now Drive Happy, LA X Dr. Do Right 777 Do Right Lane City of Gold, LA XYZ Medical Inc. 602 Yes Lane City of Gold, LA Dr. Do Right 8/28/ Z /19/04 X Claim filed for wrong DOS; will void payment and then rebill corrected 106 form. Ima Biller 9/20/ Louisiana Medicaid NEMT Provider Training 21

32 2004 Louisiana Medicaid NEMT Provider Training 22

33 FREQUENTLY ASKED QUESTIONS Q: If a recipient name is 3 characters and has a title, such as Jr. or Sr., we are receiving 217 denials (name/number mismatch). How do I get these paid? A: Enter the name on the claim exactly as it appears on the recipient s Medicaid ID card and send the claim with a cover letter of explanation to the Provider Relations Correspondence Unit (P.O. Box 91024, Baton Rouge, LA 70821). Be sure to indicate in the cover letter why the claim denied. Unisys will special handle the claim so payment can be considered. Q: Can we bill for services when the recipient doesn t sign the MT-3 form? A: You may bill for services rendered if the recipient doesn t sign the MT-3 form. You must indicate the reason why the recipient did not sign the MT-3 form in the remarks section of the claim form. Q: Can one parent be designated to ride as attendant for several children if other parents sign a permission slip? A: No. Even if permission were granted, the attendant would be totally liable for each child. The Attendant/Children Policy is explained on page 3 of this document and is for the protection of the recipients and providers Louisiana Medicaid NEMT Provider Training 23

34 CLAIM DENIALS AND RESOLUTION This section is designed to assist the provider in resolving claim denials. The most frequently encountered error codes are listed, with an explanation of each denial and how to correct it. Hardcopy Claim Denial Resolution The following explanations assume that, if the claim was filed hardcopy, no data entry errors occurred when the claim was entered into the computer system by Unisys. If the information on the remittance advice does not match the data on the claim (recipient ID number, date of service, procedure code, recipient name, charges, etc.), then a data entry error occurred. Providers may call Unisys Provider Relations department to report the problem and request that the claim be reprocessed. For Further Information The topics of recipient eligibility verification (using REVS, MEVS and e-mevs), spend-down medically needy eligibility, timely filing guidelines, SURS, and others are discussed in detail in the 2004 Basic Medicaid Provider Training packet. Providers may obtain a copy of this document by attending a 2004 Basic Medicaid Provider Training workshop, by requesting the packet from Provider Relations or by downloading from the website. General Claim Form Completion Error Codes ERROR CODE 003 RECIPIENT NUMBER INVALID OR LESS THAN 13 DIGITS Cause: The recipient ID number on the claim form was less than 13 digits in length or included letters or other non-numeric characters. Resolution: Verify the correct 13-digit recipient ID number using REVS, MEVS, or e-mevs and enter this number where required on the claim form. ERROR CODE SERVICE THRU DATE GREATER THAN DATE OF ENTRY Cause: Unisys received the claim prior to one or more dates of service billed. Resolution: Correct the date span on the claim and rebill OR wait until all dates of service on the claim have passed and rebill. Cause: Resolution: ERROR CODE INVALID OR MISSING PROCEDURE CODE 1. No procedure code was entered in block 21D of the Unisys 106 claim form, OR 2. The procedure code entered in block 21D of the Unisys 106 claim form is invalid (usually because it has fewer than five characters). Enter the correct procedure code in block 21D of the claim form and resubmit Louisiana Medicaid NEMT Provider Training 24