Wyoming Trauma Conference

Transcription

1 Wyming Trauma Cnference Wyming Medicaid Ambulance Services August 22, 2015 Presenters: Kilee Thmpsn and Melissa Davis, Field Representatives

2 CMS-1500 Prvider Manual Lcated n the Wyming Medicaid Website Select Prvider Select Prvider Manuals and Bulletins (Navigatin Bar n Left) Select Ambulance Services within the CMS-1500 Prvider Manual and Bulletins sectin Select CMS-1500 Prvider Manual Review fr New/Updated Infrmatin Imprtant Plicy Changes/Additins sectin CMS-1500 Prvider Bulletins sectin Additinal Links sectin Medicaid and State Healthcare Benefit Plans NDC Crsswalk Carrier Cde List 2

3 CMS-1500 Prvider Manual Chapters 2 9 General Infrmatin Cntains general Wyming Medicaid Plicy that relates t all prviders that bill with the CMS-1500 Claim Frm r submit an 837P claims transactin Chapter 2 Getting Help When Yu Need It Cntains phne numbers and websites Chapter 3 Prvider Respnsibilities Enrllment When t bill a client When NOT t bill a client Recrd keeping requirements 3

4 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 4 Utilizatin Review Review f claims and state/fiscal agent access t recrds Fraud and abuse, and hw t reprt Chapter 5 Client Eligibility Types f eligibility Imprtance f client identificatin Eligibility verificatin 4

5 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 6 Cmmn Billing Infrmatin Basic claim infrmatin Cmpleting the claim frm & examples Cap limits C-payments Prir authrizatin Electrnic claims with attachments Remittance Advices Adjusting claims Timely filing Failure t ntify prviders f eligibility 5

6 CMS-1500 Prvider Manual General Infrmatin Chapters 2 9 (cntinued) Chapter 7 Third Party Liability Dealing with ther insurance Chapter 8 Electrnic Data Interchange (EDI) Wyming Medicaid electrnic services Registering fr the Secured Prvider Web Prtal Chapter 9 Wyming Specific HIPAA 5010 Electrnic Specificatins Wyming Medicaid specific electrnic billing and transactin requirements 6

7 CMS-1500 Prvider Manual Cvered Services Chapter 10 Cvered Services Sectin 10.5 Ambulance Services Cvered services and billing requirements specific t ambulance services Wyming Medicaid cvers services prvided by independent ambulances r hspital-based ambulances Bth grund and air transprts, with medical interventin, t the nearest apprpriate facility are cvered All services prvided must be medically necessary 7

8 Emergency Transprtatin Medicaid cvers bth Basic Life Supprt r Advanced Life supprt if: A medical emergency exists in that the use f any ther methd f transprtatin culd endanger the health f the patient AND The patient is transprted t the nearest apprpriate facility AND The destinatin is an acute care hspital were the patient is admitted as an inpatient r utpatient 8

9 Emergency Transprtatin Medical Emergencies are cnsidered t exist under any f the fllwing circumstances: An emergency situatin, due t an accident, injury, r acute illness Restraints are required t transprt the patient The patient is uncnscius r in shck Immbilizatin is required due t a fracture r the pssibility f a fracture The patient is experiencing symptms f mycardial infarctin r acute strke The patient is experiencing severe hemrrhaging 9

10 Nn-Emergency Transprtatin Cvered when any ther mde f transprtatin wuld endanger the health r life f a client & at least ne f the fllwing criteria is met: Cntinuus dependence n xygen Cntinuus cnfinement t bed Cardiac disease resulting in the inability t perfrm any physical activity withut discmfrt Receiving intravenus treatment Heavily sedated Cmatse Pst pneum/encephalgram, myelgram, spinal tap, r cardiac catheterizatin Hip spicas and ther casts that prevent flexin at the hip Requirement fr islette in perinatal perid State f uncnsciusness r semi-cnsciusness 10

11 Service Level Definitins-Basic Basic Life Supprt Services A Basic Life Supprt (BLS) ambulance is ne which prvides transprtatin in additin t the equipment, supplies, and staff required fr basic services such as the cntrl f bleeding, splinting f fractures, treatment fr shck, and basic CPR. Basic Life Supprt Emergency Basic Life Supprt emergency services must meet ne f the criteria listed under Emergency Transprtatin and the definitin f BLS Services. Basic Life Supprt Nn-Emergency Basic Life Supprt nn-emergency services must meet ne f the criteria listed under Nn-Emergency Transprtatin and the definitin f BLS Supprt Services. 11

12 Service Level Definitins-Advanced Level 1 Advanced Life Supprt Services Advanced Life Supprt (ALS), means treatment rendered by highly skilled persnnel, including prcedures such as cardiac mnitring and defibrillatin, advanced airway management, intravenus therapy and/r the administratin f certain medicatins. Advanced Life Supprt Level 1 Emergency (ALS1-emergency) This level f service is transprtatin by grund ambulance with prvisin fr medically necessary supplies, xygen, and at least ne ALS interventin. The ambulance and its crew must meet certificatin standards fr ALS care. An ALS interventin refers t the prvisin f care utside the scpe f an EMT-basic and must be medically necessary (e.g. medically necessary EKG mnitring, drug administratin, etc.) An ALS assessment des nt necessarily result in a determinatin that the client requires an ALS level f service. Advanced Life Supprt Level 1 Nn-Emergent (ALS1 nn-emergent) This level f service is the same as ALS1-emergency but in nn-emergent circumstances. 12

13 Service Level Definitins-Advanced Level 2 Cvered fr the prvisin f medically necessary supplies and services include: 1. At least three separate administratins f ne r mre medicatins by intravenus push/blus r by cntinuus infusin (excluding crystallid fluids) 2. Grund ambulance transprt, medically necessary supplies and services, and the prvisin f at least ne f the ALS2 prcedures listed belw: Manual defibrillatin/cardi versin Endtracheal intubatin Central venus line Cardiac pacing Chest decmpressin Surgical airway Intrasseus line 13

14 Air Ambulance Services Medicaid cvers bth cnventinal air and helicpter ambulance services. These services are nly cvered under the fllwing cnditins: The client has a life threatening cnditin which des nt permit the use f anther frm f transprtatin The client s lcatin is inaccessible by grund transprtatin Air transprt is mre cst effective than any ther alternative Medicaid cvers air ambulance transfers f a client wh is discharged frm ne inpatient facility and transferred and admitted t anther inpatient facility when distance r urgency precludes the use f grund ambulance. 14

15 Dispsable Supplies and Oxygen Dispsable and Nn-Reusable Supplies are Cvered A maximum f five units is allwed fr supplies Gauze and dressings Defibrillatin supplies IV drug therapy dispsable supplies Oxygen and related dispsable supplies are cvered nly when the client s cnditin at the time f transprt requires it It is nt cvered when it is prvided nly n the basis f prtcl 15

16 Mileage Wyming Medicaid will nly reimburse mileage fr laded miles Pickup t Destinatin Laded mileage is cvered in additin t the base rate fr all air transprts Mileage must be medically necessary Mileage is equal t the shrtest rute t the nearest apprpriate facility, with regards t cnstructin and rad cnditins Billing requirements: One (1) unit = ne (1) statue (map) mile This applies t bth air and grund transprt Mileage must be runded t the nearest mile Ex miles = 17 miles/units & 17.5 miles = 18 miles/units 16

17 Nn-Cvered Services Transprtatin fr nn-cvered services r t pick up pharmaceuticals Unladed mileage Clients wh are prnunced dead befre r after an ambulance is called but befre transprtatin Transprtatin f a family member/friend Return trip t hme/nursing hme when nt medically necessary Transprtatin t a mental health facility if n ther criteria is met Transprtatin t anther facility based ff preference Transprtatin f a client in respnse t detentin rdered by a curt r law enfrcement agency r physician s standing rders Stand-by Time, Special Attendants, SCT, PI Transprt fr an utpatient service Transprtatin f a client having suicidal ideatins if n ther criteria is met 17

18 Multiple Client Transprtatin & Usual and Custmary Charges Mre than ne client can be transprted at ne time hwever The base rate will be reimbursed nce Mileage will be reimbursed nce Each clients supplies will be reimbursed separately Usual and Custmary Charges Always bill usual and custmary charges t Wyming Medicaid This infrmatin is used t calculate Wyming Medicaid payment rates 18

19 Identifying an Emergency Service When Billing Reminder, effective February 1, 2015 Wyming Medicaid will n lnger be identifying an emergency service by diagnsis cde An emergency indicatr will need t be entered n the claim ( Bx 24c, EMG r Lp 2400) Very imprtant fr nn-citizens All indicated emergency services must be supprted with medical dcumentatin kept n file with the prvider s ffice C-pays C-pay fr nn-emergency services still apply C-payment requirements d nt apply t emergency services Nte: C-pays d nt apply t ambulance services 19

20 Billing Requirements Prcedure Cde Descriptins GROUND/Basic Life Supprt (BLS) A0380 BLS mileage (per mile) $5.63 Current Rate A0382 BLS rutine dispsable supplies $10.00 A0422 Ambulance (ALS r BLS) xygen and xygen supplies, life sustaining situatin $25.00 A0425 Grund mileage, per statute mile $5.63 A0428 Ambulance service, basic life supprt, nn-emergency transprt, (BLS) $ A0429 Ambulance service, basic life supprt, emergency transprt (BLS, emergency) $ GROUND/Advanced Life Supprt (ALS) A0390 ALS mileage (per mile) $5.63 A0398 ALS rutine dispsable supplies $12.00 A0422 Ambulance (ALS r BLS) xygen and xygen supplies, life sustaining situatin $25.00 A0425 Grund mileage, per statute mile $5.63 A0426 Ambulance service, advanced life supprt, nn-emergency transprt, level 1 (ALS1) $ A0427 Ambulance service, advanced life supprt, emergency transprt, level 1 (ALS1-emergency) $ A0433 Advanced life supprt, level 2 (ALS 2) $ Air Ambulance A0430 Ambulance service, cnventinal air services, transprt, ne way (fixed wing) $ A0431 Ambulance services, cnventinal air services, transprt, ne way (rtary wing) $ A0435 Fixed wing air mileage, per statute mile $9.08 A0436 Rtary wing air mileage, per statute mile $24.23

21 Trip Reprts & Electrnic Claims Mandate Trip Reprts must be submitted with each ambulance claim All claims must be submitted electrnically There are tw ptins fr submitting trip reprts as attachments t electrnic claims (d nt frget t indicate n the claim there will be an attachment submitted) 1. Submit paper trip reprt by cmpleting the Attachment Cntrl Dcument frm This frm may be fund at >Frms->Wyming Medicaid Miscellaneus Frms 2. Submit electrnic cpy f trip reprt by lgging int the Wyming Medicaid Prvider Prtal and uplading the attachment thrugh the Electrnic Attachments link Directins fr cmpleting the steps may be fund at htt://wymedicaid.acs-inc.cm->prvider->web Prtal Tutrials 21

22 Cmmn Denial Reasns and Slutins Services billed are nt supprted This usually results frm a prvider billing ALS when nly BLS services are supprted Billing shuld be t the highest degree f accuracy Slutin It is imprtant t review which services fall within each categry f services cvered fr ambulance services Review trip reprt t verify that service billed is supprted thrugh dcumentatin 22

23 Cmmn Denial Reasns and Slutins Mileage Wyming Medicaid nly cvers mileage fr laded miles In additin, mileage shuld be frm pickup t destinatin Wyming Medicaid fllws nrmal runding rules 0.5 and up-please rund up 0.49 and dwn-please rund dwn Slutin Review trip reprt fr accurate trip mileage and rund accrdingly Rund the mileage n bth the trip reprt and claim Dcument air mileage separately frm grund transprt mileage 23

24 Cmmn Denial Reasns and Slutins Pr Trip Reprts N dcumentatin supprting level f service billed Unreadable/pr images/nt legible/client infrmatin cannt be determined Mileage Nt runded r dcumented crrectly (miles billed must match reprt rund in bth places) Air and grund mileage must be clearly dcumented and billed separately Slutins If recrds are hand written, make sure writing is legible and prvides all necessary infrmatin If recrds are scanned/faxed, make sure recrds are dark, and clear 24

25 Cmmn Denial Reasns and Slutins Air vs. Grund Transprtatin When a client receives bth an ambulance trip and air ambulance trip in the same encunter, mileage fr each prtin needs t be separate and clear Slutins Verify trip reprt is clear and supprts mileage billed Als needs t supprt bth methds f transprtatin 25

26 References The infrmatin reviewed in this presentatin may be fund in the CMS Manual Wyming Medicaid Website Prvider Manuals and Bulletins Click n Prvider / Prvider Manuals and Bulletins / Ambulance / CMS-1500 Prvider Manual Fee Schedule Click n Prvider / Fee Schedules / Accept / Prcedure Cde Search Page IVR Navigatin Tips Helps t direct prviders t the apprpriate ptins fr each department Click n Prvider / Cntact Us / Click here fr helpful Prvider IVR Navigatin Tips Remittance Advice Retrieval Frm the Secure Prvider Web Prtal Medicaid and State Healthcare Benefit Plan dcument Click n Prvider / Prvider Manuals and Bulletins / Additinal Links 26

27 References IVR hurs a day / 7 days per week NPI is required IVR Functinality Verify client eligibility Client ID r client SSN and date f service is required Benefit plan Cvered services Limitatins Cap Limits Lck-in TPL / Medicare Buy-in Verify claim status Verify Payment Opt ut t an agent Medical Plicy (Optin 1,1,4,3) 9-5 MST Mnday - Friday 27

28 References Prvider Relatins (Opt ut t an agent ptins 1,5,0) 9-5 MST Mnday - Friday Bulletin / Manual inquiries Claim inquiries / vids / adjustments Claim submissin prblems Client eligibility Questins n cmpleting frms Payment inquiries Timely filing inquiries Verifying validity f prcedure cdes EDI Services Optin MST Mnday Friday EDI Enrllment Frm Prvider Web Prtal Registratin Technical Supprt fr Prvider Web Prtal Prvider Web Prtal Training Passwrd Resets 28

29 Questins? 29

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