JANUARY MARCH 2013 PROVIDER OFFICE TALKING POINTS

Transcription

1 JANUARY MARCH 2013 PROVIDER OFFICE TALKING POINTS 1

2 AHCCCS Information and Updates Primary Care Services Rates Beginning January 1, 2013, AHCCCS will conform to the federal requirements in Section 1202 of the Affordable Care Act, which requires Medicaid programs to reimburse designated primary care providers who provide primary care and vaccine administration services at specified rates. See the link below for more information: On November 6, 2012, the Centers for Medicare and Medicaid Services (CMS) published final rules effective January 1, 2013 that set forth the requirements for State Medicaid Agencies mandated by Section 1202 of the ACA. CMS has authorized States until March 31, 2013 to submit their methodologies to CMS for approval. The final rules clarify that approvals of timely State submissions will be retroactive to January 1, AHCCCS is in the process of developing its methodologies and will issue further guidance in the near future. AHCCCS and its contracted health plans will follow the procedures, processes and policies that are being developed by the federal government. Although these requirements are mandated by the federal government, AHCCCS apologizes for the increased burden this will place on providers and requests that providers be patient as the agency works through the many challenging issues that result from these new requirements. Section 1202 of the Affordable Care Act requires that Medicaid reimburse designated primary care providers who provide primary care services and vaccine administration services at rates that are not less than the Medicare fee schedule in effect for 2013 and 2014, or, if greater, at the payment rates that would result from applying the 2009 Medicare physician fee schedule conversion factor to the 2013 or 2014 Medicare payment rates. These reimbursement requirements apply to payments provided from January 1, 2013 through December 31, Refer to the attached AHCCCS Memo released December 17, 2012 for more information. Additional questions may be directed to the following e mail address: PrimaryCareRates@azahcccs.gov 2

3 New Requirements for Submission of Claims for Vaccine Administration REVISED 1/14/2013 RETRO EFFECTIVE 1/1/2013 Due to the change in Federal regulations of Section 1202 of the Patient Protection and Affordable Care Act (ACA), Section 1202 also requires AHCCCS and its Contractors to pay vaccine administration services described by CPT codes 90460, 90461, 90471, 90472, and As part of this fee increase (see above Primary Care Services Rates), CMS requires state Medicaid programs, including AHCCCS, to modify how providers submit claims for vaccine administrative services. Effective January 1, 2013, AHCCCS will require all providers to submit two CPT codes for vaccine services: CPT code to identify the vaccine administration service and CPT code to identify the vaccine administered Beginning January 1, 2013, the administration of this vaccine would be reported with two codes: a) SL (DTaP vaccine) and b) SL (Immunization administration). No payment would be made for the vaccine if provided through the Vaccine For Children s (VFC) program. Payment will be made for the administration at the rates in effect for that service at the time the immunization is administered. The following example shows how the vaccine administration codes should be submitted on claims after January 1, 2013: No payment will be made for the vaccine if provided through the VFC (you must still include the SL modifier for VFC administered vaccines). Payment will be made for the administration at the rate in effect for that service at the time the immunization is administered. KidsCare II Re Opens On November 1, 2012, AHCCCS reopened enrollment in the KidsCare II program and all applications will be considered for eligibility. Eligibility requirements for KidsCare II will remain the same. Additionally, children on the wait list that was started Sept 7th, 2012 will automatically be enrolled into the program if they meet the eligibility requirements for KidsCare II and do NOT need to reapply at this time. AHCCCS will continue to consider all applications for KidsCare II until the program reaches maximum enrollment based on available funding. More information about the KidsCare II program is available through the toll free hotline (operated by a Community Partnership) at:

4 Childless Adults Continuation Update: On December 10, 2012, CMS informed Governors that states will not receive enhanced federal funding unless they agree to expand their programs to the fullest extent under the Affordable Care Act (up to 133% FPL). CMS provided the State specific guidance that requests such as the one proposed in Arizona s Childless Adults Waiver (Childless Adults 0 100% FPL), would not be eligible for enhanced federal funding. Thus, Arizona can only obtain enhanced federal funding for the coverage of Childless Adults if it expands Medicaid to 133% FPL. The CMS FAQ link below provides additional information. Arizona is still awaiting a formal reply from CMS on its Childless Adults Waiver request and whether it can continue coverage of Childless Adults under the 1115 Waiver beyond More information will be posted as it becomes available pdf AzAHP Credentialing Alliance The Arizona Association of Health Plans (AzAHP) is pleased to announce the creation of a new credentialing alliance aimed at making the credentialing and recredentialing process easier by eliminating duplication of efforts and reducing administrative burden. The new credentialing process was launched on October 1, Eight health plans that have agreed to participate in the AzAHP credentialing alliance: 1. Care1st Health Plan Arizona / ONECare by Care1st Health Plan Arizona 2. Comprehensive Medical and Dental Program (CMDP) 3. Health Choice Arizona / Health Choice Generations 4. Mercy Care Plan / Mercy Care Advantage / Mercy Care Long Term Care / Mercy Healthcare Group 5. Phoenix Health Plan / Abrazo Advantage Health Plan 6. SCAN Health Plan Arizona 7. UnitedHealthcare Community Plan 8. The University of Arizona Health Plans (UAHP) University Family Care / Maricopa Health Plan / University Care Advantage / University Healthcare Group As part of the new, streamlined process, the above plans have agreed to utilize the Council for Affordable Quality Healthcare (CAQH) Universal Provider Datasource for all practitioner credentialing applications and a common paper application for all facility credentialing applications. The plans have also developed a common practitioner data form and organizational data form to collect information necessary for their contract review process and system loading requirements. If you have any questions regarding the new process, please go to our website at or contact your Provider Relations Representative. 4

5 FRAUD, WASTE & ABUSE Definition of Fraud Fraud is defined by Federal law (42 CFR 455.2) as "an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law." Definition of Abuse of the Program Abuse is defined by Federal law (42 CFR 455.2) as "provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program." Definition of Abuse of a Member Abuse of a member, as defined by Arizona law (A.R.S & ), means any intentional, knowing or reckless infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, emotional or sexual abuse, or sexual assault. Examples of Fraud & Abuse Some examples of member and provider fraud and abuse are provided as follows: Member Fraud & Abuse Eligibility Determination Issues that include the following items: o Resource Misrepresentation (Transfer / Hiding ) o Residency o Household Composition o Citizenship Status o Unreported Income o Misrepresentation of Medical Condition o Failure to Report Third Party Liability (TPL) Provider Fraud & Abuse Falsifying Claims/Encounters that include the following items: o Alteration of a claim o Incorrect coding o Double billing o False data submitted Administrative/Financial actions that include the following items: o Kickbacks o Falsifying credentials o Fraudulent enrollment practices o Fraudulent Third Party Liability (TPL) Reporting o Fraudulent Recoupment Practices Falsifying Services that include the following items: o Billing for Services / Supplies Not Provided o Misrepresentation of Services / Supplies o Substitution of Services 5

6 NDC BILLING REQUIREMENTS FOR HCFA CLAIM SUBMISSIONS Phoenix Health Plan (PHP) has noticed an increasing volume of claims requiring NDC codes that are being submitted with either no NDC or a misplaced NDC. The placement of the NDC is critical on both electronic and paper claim submissions. Below is the AHCCCS requirement of NDC placement when billing a HCPCS drug or CPT code as defined: HCPCS codes that require the NDC information on the claim submission A, C, J, Q and S codes as applicable Not otherwise classified and Not otherwise specified drug codes 9e.g., J3490, J9999 and C9399) CPT codes, for immune globulins CPT codes for vaccines and toxoids. All of the following qualifiers are required for processing of claim. Claim will deny if any of the following is missing. To report the NDC on the claim form, enter the following information: CMS 1500 Claim NDC Requirements Enter the NDC Qualifier of N4 in the first 2 positions Followed by the 11 digit NDC (no dashes or spaces) and then a space Followed by the NDC Units of Measure Qualifier, Followed by the NDC Quantity. NDC Unit of Measure based on the numeric quantity administered and the unit of measurement. (If reporting a fraction, use a decimal point). The units of measurement codes are as follows: o F2 International Unit o GR Gram o ML Milliliter o UN Unit (each) Example of CMS 1500 Claim Box 24A NDC placement here in the pink shaded area and must be left justified. Note: The billed units in column G (Days or Units) should reflect the HCPCS units and not the NDC units. Note: The submission of multiple NDCs per HCPCS is not allowed. 6

7 RENDERING PROVIDER BILLING REQUIREMENTS The AHCCCS Office of Inspector General (OIG) has identified a number of claims and/or encounters that are in violation of AHCCCS Rules and Policy related to Rendering Providers. The OIG is auditing claims and/or encounters to identify this improper activity which may result in the denial of claims, recoupment of funds or the issuance of Civil Monetary Penalties. ALL claims and/or encounters must be submitted to Phoenix Health Plan (PHP) and Abrazo Advantage Health Plan (AAHP) with the appropriate rendering provider as defined below: CMS 1500 Provider Definitions [Rendering Provider]: states The rendering provider is the individual who provided the care to the client. In the case where a substitute provider was used, that individual is considered the rendering provider. AHCCCS Fee for Service Provider Manual: states Physician and mid level practitioners must register with AHCCCS and bill for services under their individual NPI numbers. AHCCCS Participating Provider Agreement [#19]: states that No provider may bill with another provider s ID number, except in locum tenens situations. CMS Manual System Pub Medicare Claims Processing: states Enter the rendering provider s NPI number in the lower unshaded portion. Rendering or substitute provider, (Physicians, Physician Assistant, Nurse Practitioner, Affiliated Practice Dental Hygienist, et al), must bill with their own NPI number which must be registered with AHCCCS. Rendering/Substitute provider: Bill with their own NPI in Box 24J Bill with modifier Q5 in Box 24D If the substitute provider is not a part of the practice, they should bill with their own Tax ID in Box 25. Locum Tenens arrangement is when a physician is retained to assist the regular physician s practice for reasons such as illnesses, pregnancy, vacation, or continuing medical education. Locum Tenens generally have no practice of their own and travels from area to area as needed. Locum Tenens can cover the physician up to a period of 60 days. Locum Tenens: The locum tenens provider must submit claims using the AHCCCS provider ID number and Tax ID of the physician for who the locum tenens provider is substituting or temporarily assisting. Bill with modifier Q6 in Box 24D The code(s) being billed must qualify for the Q6 modifier for payment. 7

8 How to read a Claims Inquiry on the Web Portal Phoenix Health Plan (PHP) and Abrazo Advantage Health Plan (AAHP) encourage our providers to utilize our secured web portals to status claims. Please allow up to 3 weeks before following up on the claim. Here is how to view the Claims Inquiry screen. Pending Example: Take note that the check information is blank. This is the key indicator that the claim has not yet been processed and is still pending. Processed example: This is NOT an indicator that the claim has been processed. These are system generated codes and subject to change once the claim has been processed. Processing/Payment Indicator: If the check number and date is blank the claim has not been processed. Processing/Payment Indicator: There is a check number and date in the fields. For claims that are paid or denied, each claim line will always have a check number and date populated in these fields. 8

9 9

10 10