Policy, Coverage, and
Benefits
HP Provider Relations
October 2010
Agenda
– Medical Policy Objectives
– Policy Consideration Process
– Coverage and Benefits
– Policy Clarification/Inquiries
– Approved Provider Code Sets
– Provider Notifications
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Policy, Coverage, and Benefits
October 2010
Objectives
At the end of this session, providers will better understand:
– How to request a policy change
– How to inquire about current policy
– When procedure codes are reviewed
– Provider code sets
– Indiana Health Coverage Programs (IHCP) tools used for provider
notifications
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Policy, Coverage, and Benefits
October 2010
Learn
OMPP Policy Consideration
OMPP Policy Consideration Process
–
To advance a value-driven program focusing on cost-effective
improvements to the health of the Indiana Medicaid population, the
Office of Medicaid Policy and Planning (OMPP) has created a
structured policy consideration process
–
The policy consideration process allows a Medicaid provider,
manufacturer, or member to request changes to current Medicaid
policy
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Policy, Coverage, and Benefits
October 2010
What Does the Policy Consideration Unit Do?
–
The Policy Consideration Unit facilitates the policy consideration
process by acting as a receiving point for policy requests and
presenting those requests to the Policy Evaluation Team (PET)
Note: The PET is a group of representatives from throughout the
OMPP that deliberates and makes decisions on policy requests
for determination of further action
–
Use of the policy consideration process is an opportunity for providers
to reach out to the OMPP with policy-related questions and
suggestions
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Policy, Coverage, and Benefits
October 2010
How Do I Submit a Request to the Policy
Consideration Unit?
– If you would like to submit a policy request, send an e-mail with
your request to the OMPP policy consideration mailbox at:
Policyconsideration@fssa.in.gov
– If you are requesting clarification of a current policy, submit your
question to:
Written Correspondence
P.O. Box 7263
Indianapolis, IN 46207-7263
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Policy, Coverage, and Benefits
October 2010
What Happens after I Submit a Policy
Consideration Request?
– You will receive a notification e-mail of the receipt of your policy
consideration with a request to complete a one-page form to fully
detail your request
– If an item is placed into the policy evaluation process, the Policy
Consideration staff develops a brief summary of the issue, which
will be presented to the Policy Evaluation Team and a
determination for further action will be made
– The Policy Consideration Unit will notify you via e-mail of the
determination made by the Policy Evaluation Team regarding your
request
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Policy, Coverage, and Benefits
October 2010
Policy Consideration Criteria Examples
– A change in policy
•
Age restriction
•
New program
– Linkages with revenue code or procedure code
•
New covered codes
•
Modifiers
– Request for current policy review
•
Review of Provider Manuals
– Request for review of bundled codes
Note: Do not use Policy Consideration for items such as
reimbursement rates or claim processing errors
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Policy, Coverage, and Benefits
October 2010
Policy Consideration: A Case Study
Scenario: A manufacturer requested policy changes to the bariatric
surgery policy. The request included:
• Change minimum age from 21 years to 18 years
• Lower the required duration for physician-supervised nonsurgical medical treatment
from 18 months to 6 months
–
–
–
–
–
–
–
Research was conducted by the Policy Consideration Unit
Findings were presented to the PET
Additional research was requested by the PET
The PET reviewed all the findings and made a recommendation to
approve the policy change
The PET forwarded its recommendation to the Executive Team,
which makes the final determination of the request
Executive Team approved request
Manufacturer was notified of approval of request
Policy change was implemented
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Policy, Coverage, and Benefits
–
October 2010
Define
Coverage and benefits
Function of the Coverage and Benefits Unit
– Define coverage and benefit
policies
– Coordinate with other contractors,
such as HP, Myers & Stauffer, and
Milliman
– Review procedure codes
– Draft new coverage policies
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Policy, Coverage, and Benefits
October 2010
Coverage and Benefits
–
All inquiries should be directed to the HP Customer Assistance Unit
or your HP provider field consultant
–
Types of inquiries include*:
• Review of claim denials
• Billing questions
• Claim submission questions
• Provider and Member Services
• Clarification of medical policy
• Healthcare Common Procedure Coding System (HCPCS); Current Procedural
Terminology (CPT®); International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9-CM); and Revenue Codes
* This list is not all-inclusive
CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Policy, Coverage, and Benefits
October 2010
Inquiry Review, Process/Response
–
Many provider inquiries can be answered by:
• Contacting HP Customer Assistance
• Referring to existing publications, such as banner pages, bulletins, provider
manuals, and IHCP Web site
• Viewing the IHCP fee schedule
–
Some inquiries may require referral to the appropriate
agency or contractor
Note: Publications, the IHCP fee schedule, program manuals, and the
IHCP Provider Manual are available at
www.provider.indianamedicaid.com
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Policy, Coverage, and Benefits
October 2010
Review
Procedure Code Review Process
Procedure Code Reviews
– Annual and quarterly
HCPCS updates
– Annual ICD-9-CM updates
– Provider code sets
– Coding inquiries specific to
policy coverage
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Policy, Coverage, and Benefits
October 2010
Approved Provider Code Sets
– Providers whose enrolled specialties
correspond with an active code set are
reimbursed only for services within that
specific code set(s)
– Claims billed with HCPCS/CPT codes not
included in a provider’s code set are
denied with edit 1012 – Rendering
Provider Specialty Not Eligible to Render
Procedure Code
– For providers with multiple specialties,
claims processing will review the provider
file for all specialties when claims are
submitted
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Policy, Coverage, and Benefits
October 2010
Provider-Specific Code Sets
The following code sets are available at
www.provider.indianamedicaid.com:
–
Chiropractic
–
Durable Medial Equipment (DME)
–
Home Medical Equipment (HME)
–
HIV Care Coordinators
–
Hearing Services (Audiology and Hearing Aid Dealers)
–
Optometrists
–
Opticians
–
Transportation
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Policy, Coverage, and Benefits
October 2010
Provider Notifications
– Banner Pages – clarify policies, provide notice of
system changes, and provide notice of minor
policy changes
– Bulletins – provide notice of major policy changes
or new policy
– Newsletters – provide information that could be
published in banner pages or bulletins and can
include rule changes
– Provider Manual – provides information on
medical policy and billing instructions
Note: Provider can sign up for automatic e-mail
notifications via the Indiana Medicaid Web
site
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Policy, Coverage, and Benefits
October 2010
Web Site References
Indiana Health Coverage Programs
http://www.indianamedicaid.com
Indiana Family and Social Services Administration
http://www.in.gov/fssa/
Indiana Administrative Code
http://www.in.gov/legislative/ic/code
Centers for Medicare & Medicaid Services
http://www.cms.hhs.gov
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Policy, Coverage, and Benefits
October 2010
Q&A
