Volume VI; June 2013 ATTENTION PRACTICE MANAGERS MUST USE Easier to Read Asterisks detailing required information New telephonic team working to give you timely status updates AZPCP Prior Authorization Department BENCHMARKS a ROUTINE Prior Authorization Turn- Around-Time (TAT) of 72 hours MEDICAL DIRECTOR CONTACT NUMBER ON FORM FOR ALL STAT-REQUESTS! All Stat requests will require direct approval with an AZPCP Medical Director. For questions, or assistance contact: Jennifer Devin, RN (480) 499-8737 CMS provides criteria as to what categorizes a STAT or URGENT Request. Application of the standard time period for making a non-urgent referral could seriously jeopardize a member s life, health or ability to regain maximum function. In the opinion of a practitioner with knowledge of the member s medical condition, the member would be subjected to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request. To avoid possible post-payment audits or denial of services, Medicare requires completion of a written radiology interpretative report when billing for Technical Component (TC) and modifier -26 component. http://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c13.pdf Medicare Claims Processing Manual, Chapter 13-Radiology Services and Other Diagnostic Procedures, Section 20.1 Professional Component (PC). Page 1
Effective January 1, 2011, for claims processed on or after January 1, 2011, submission of the location where the service was rendered will be required for all POS codes. Only one name, address and ZIP code may be entered in the block. If additional entries are needed, separate claim forms shall be submitted. http://www.cms.gov/regulations-and- Guidance/Guidance/Transmittals/downloads/R2284CP.pdf The Office of the Inspector General has targeted modifier -25 for overuse with a special fraud alert, so use caution when reporting an E/M service with a procedure with modifier -25. Medicare and/or third-party payers may require Pre-payment and/or Post-payment review of this code. No documentation is required to be submitted before payment unless there are special circumstances related to the patient encounter. When billing modifier -25: Make sure the diagnosis code is correctly linked to the procedure and/or E/M service. If the only service provided is the procedure, an E/M code with modifier -25 may not be appropriate. Use modifier -25 only when the E/M service is significantly and separately identifiable from the procedure or other service performed on the same day. When billing preventive medicine services and problem-oriented E/M services on the same day with modifier -25, make sure the problem is significant and requires additional work to perform the key components of a problem-oriented E/M service. Grider, Deborah J., (2011).Coding with Modifiers, A Guide to Correct CPT and HCPCS Level II Modifier Usage, Fourth Edition, Modifiers 25 to 47 (pp 66-67). United States of America: American Medical Association. Prior authorization requests for radiology services are initiated by the Referring Physician (PCP/Specialist). When requesting a Prior Authorization for Radiology, the referring physician should complete the Authorization Request Form and Fax it to the A z PCP Prior Authorization department for review. Do not send your order/script to the radiology facility. Page 2
Any time you have changes in your practice, e.g. physicians joining or leaving, new tax identification number, office location changes, etc., you need to notify A z PCP in writing. Use the attached form to provide us the updated information. A z PCP strives to keep its provider partners updated on a regular basis. Our preferred method of communicating these changes to you is via email. Please provide us your preferred email address for provider updates. Please complete the attached form and return it to us and we will update our records. Note: If you don t return this form, we will continue to send your communications via fax. Please direct your inquiries to our patient and Provider Service Department who offers up-todate information with regard to eligibility, authorization, and claims status. Note: Calling the Provider Services department will ensure that your call is documented. A Z PCP PATIENT AND PROVIDER SERVICES DEPARTMENT Monday Friday, 7 AM 5:30 PM Provider Services (480) 499-8720 or (480) 499-8700, Option 1 Patient Services (480) 499-8750 or (480) 499-8700, Option 2 Page 3
As a contracted A z PCP provider, you are required to bill A z PCP for services rendered to a Health Net Medicare Advantage member. Billing A z PCP for these members will reduce issues related to payment and recoupment. Electronically: Emdeon at 1-877EMDEON-6 or (877) 363-3666 or Sign-up online at www.emdeon.com Payor ID is 27154 or Office Ally at (866) 575-4120, then select Enrollment or sign-up online at www.officeally.com, click on Enroll Now Payor ID is AZPCP (all CAPS) Mail Paper Claims to: Arizona Priority Care Plus ATTN: Claims Department 6165 West Detroit Street Chandler, AZ 85226 Page 4
COMMUNICATION NOTICES Please tell us your preferred email address for A z PCP Provider Updates. Please check and complete your preferred email address below. Email: Complete email address Physician/ Practice Name Physician/ Practice Street Address City State Zip Code ( ) Name of Person Completing Form Area Code Phone Number Please Fax this completed form to: Arizona Priority Care Plus (A z PCP) Provider Networks (480) 499-8729 Page 5
A z PCP Prior Authorization Request Form Please fill out the form in its entirety. The Authorization could be delayed and/or denied if all required fields are not completed. Required fields are marked with an asterisk (*). FAX: 480-499-8798 / 855-711-2915 *Patient Name: PATIENT DATA *Patient Phone Number: *Patient Address: *City: *Zip code: *Patient Insurance ID: *Date of Birth *Procedure or Treatment Requested/Date of Service MEDICAL HISTORY *Requesting Provider: *Diagnosis code (ICD-9): *Procedure codes (CPT's): *Type of service Outpatient Inpatient Office *Facility to provide service Type of Request All referral requests will be processed as routine unless there has been documented communication with an AzPCP Medical Director. You may speak to a Medical Director by calling (480) 499-8735. *Please enter the name of the Medical Director spoken with. *** Please note Medicare's definition of a STAT request is as follows: "The standard review timeframe may seriously jeopardize the life or health of the Member, or the Member's ability to regain maximum function*** The following records MUST be submitted with this referral (commenting is not sufficient): Nurses Notes * Medical Records * *Contact Name: *Contact Phone Number and Fax Number: #Visits Requested #Visits Approved Payment is authorized only for the medical services noted above, and is subject to the limitations and exclusions as outlined in the Member's Evidence of Coverage. This decision may be appealed through the health plan's grievance procedure as outlined in the members Evidence of Coverage. Rev. 060113 Effective Dates: to PRIOR APPROVAL IS REQUIRED FOR SERVICES BY ANY NON-PARTICIPATING PROVIDER. Mail to: AzPCP, Attn: Pre-Certification Department, 6165 West Detroit Street, Chandler, AZ 85226 PHONE: 480-499-8730 / 855-711-2914