Presumptive Eligibility/
Notification of
Pregnancy Updates
and Billing
HP Provider Relations
October 2011
Agenda
– Session Objectives
– Overview
– Qualified Providers
– Presumptive Eligibility Member
Qualifications
– Eligibility Verification System
– Notification of Pregnancy
– Helpful Tools
– Questions
2
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Objectives
Following this session, providers will:
–
Have an understanding of the Presumptive Eligibility program
–
Understand the responsibilities of a qualified provider
–
Understand who qualifies for Presumptive Eligibility
–
Understand the Eligibility Verification System options
–
Be able to see the successes of PE enrollment across the state
–
Be able to see where there is access to PE across the state
–
Have an understanding of the Notification of Pregnancy
3
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Define
Overview
Presumptive Eligibility – What Is
It?
5
–
For a limited period of time, a
pregnant woman, who has been
determined by a qualified provider
(QP) to be presumptively eligible may
receive ambulatory prenatal services
while her Hoosier Healthwise
application is being processed
–
Inpatient care, hospice, long-term
care, delivery services, postpartum
and services unrelated to the
pregnancy or birth outcome are not
covered
–
Implementation of the Presumptive
Eligibility program began July 1, 2009
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Who Is Eligible for Presumptive
Eligibility?
To be eligible for Presumptive Eligibility
(PE), a pregnant woman must:
6
–
Be pregnant, as verified by a
professionally administered pregnancy
test
–
Not be a current Medicaid member
–
Be an Indiana resident
–
Be a U.S. citizen or a qualified
noncitizen
–
Not be currently incarcerated
–
Have gross family income less than
200 percent of the federal poverty level
(FPL)
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Benefit Packages
–
Package A – Standard Plan
–
Package B – Pregnancy Coverage
–
Package C – Children’s Health Plan
–
Package E – Emergency Services
Only
–
HIP – Healthy Indiana Plan
–
Package P – Presumptive Eligibility
for Pregnant Women
7
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Presumptive Eligibility Income
Standards
8
Family Size
Monthly
Income
Annual
Income
2
2,429
29,148
3
3,052
36,624
4
3,675
44,100
5
4,299
51,588
6
4,922
59,064
7
5,545
66,540
8
6,169
74,028
Add $624/mo
for each
additional
person
Add $7,476/yr
for each
additional
person
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Why Presumptive Eligibility Is
Important
9
–
Early enrollment in Medicaid is
associated with better birth outcomes
–
PE may help lower one of the barriers
that prevent low income, uninsured
women from seeking early prenatal care
–
Allows providers to be reimbursed for
prenatal services provided earlier in a
woman’s pregnancy
–
Public Law 218-2007 (HEA 1678) was
passed by the State Legislature and
signed by the Governor in 2007
–
Section 55 of this law directed the Office
of Medicaid Policy and Planning
(OMPP) to apply for federal approval of
presumptive eligibility for pregnant
women
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Learn
Presumptive Eligibility Statistics
Presumptive Eligibility Statistics
–
20,866* Women enrolled in
Presumptive Eligibility (PE)
–
19,106 Women enrolled in PE with
Medicaid decision:
–
14,848* (78%) Women approved for
Hoosier Healthwise through PE
–
4,258* (22%) Women on PE with Medicaid
denial.
*Data reflective of services from July 1, 2009, to August 2, 2011
11
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Learn
Qualified providers
Who Can Be a Qualified Provider?
QPs may include the following provider
types/specialties:
– Family or general practitioner
– Pediatrician
– Internist
– Obstetrician or gynecologist
– Certified nurse midwife
– Advanced practice nurse practitioner
– Federally qualified healthcare center
– Medical clinic
– Rural health clinic
– Outpatient hospital
– Local health department
– Family planning clinic
13
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Who Can Be a Qualified Provider?
QPs must meet the following federal and State requirements
Federal requirements:
–
Must be enrolled in Medicaid
–
Must provide outpatient hospital, rural health clinic, or clinic
services as defined in sections 1905 (a)(2)(A) or (B), 1905(a)(9),
and 1905(l)(1) of the Social Security Act
–
Must be trained and certified by the State (or designee) to
perform PE functions
State-specific requirements:
–
Must be able to verify pregnancy via a professionally
administered pregnancy test
–
Must have Internet, telephone, printer, and fax access that is
available to facilitate the PE and Medicaid application process
–
Must have Administrator access to Web interChange
•
14
Complete the Administrator Request Form to set up an administrator
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Are there Qualified Providers across the State?
–
275 Qualified Providers (QP) have
enrolled
–
–
Only ½ the counties in IN have more than 1
QP point of access
Only 7 counties with 10 or more QP
locations
–
–
–
–
–
–
–
Allen – 13
Elkhart – 20
Lake – 20
Madison – 10
Marion – 37
Vanderburgh – 10
Vigo – 15
In many Counties there is still a
need for QP’s
−Do
15
you know where a QP is located in your county?
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Locating a Qualified Provider
To locate a qualified provider, go to the IHCP Web site at
www.indianamedicaid.com
–
Qualified providers are location-specific
–
Each location must be trained by the State or its designee
Note: As a QP site, please ensure that all staff members in all
associated locations are trained to assist prospective
PE applicants or to refer them to a location that has
personnel trained by the state or its designee to assist
them in the PE application process
16
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Explain
Eligibility verification
Eligibility Verification
–
The Eligibility Verification
System (EVS) communicates
information about women with
PE the day following the
determination by the qualified
provider and activation by
MAXIMUS
– EVS options include:
• Web interChange
https://interchange.indianamedicaid.com/
Administrative/logon.aspx
• Omni machine
• Automated Voice Response (AVR)
(317) 692-0819 or 1-800-738-6770
Note:
18
Only Web interChange can be used to submit a
member application for PE
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Describe
Notification of Pregnancy (NOP)
What Is the Notification of
Pregnancy?
The OMPP, managed care entities (MCEs), Indiana State Department
of Health (ISDH), and other Medicaid stakeholders worked jointly to
develop a universal assessment for pregnant women to capture:
•
•
•
•
•
•
•
•
•
•
20
Maternal Obstetrical History
History of Prior Births (Still birth, Pre-term, Low Birth Weight)
Diagnosis of Pregnancy Risk
Maternal Medical History (including conditions that require management during
pregnancy, such as hypertension and diabetes)
Current Medications
Mental Health History and Current Conditions
Substance Abuse/Use History
Tobacco Use History
Social Risk Factors
Needed Referrals
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Notification of Pregnancy
Medicaid Goals:
– Identify health risk factors early in Medicaid-eligible women
– MCEs review and provide care coordination to high risk pregnant women
– Increase the percentage of pregnant women assessed within
the first trimester
– NOP data for women on PE demonstrates entry into prenatal care earlier
– 67% of the women on PE enter care during the first trimester
– 40% of all other women receive an NOP in the first trimester

Reduce smoking rates for pregnant women

Monitor pregnant women with a BMI >30
21
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Notification of Pregnancy
19,559 NOP’s completed
–
–
5,689 NOPs for women on PE
–
13,870 NOPs for all other members
NOPs completed during each trimester
–
–
First trimester – 9,250
–
Second trimester – 9,100
–
Third trimester – 1,209
NOP identified pregnancy risks
–

–
Normal – 69% (13,459)
–
High – 31% (6,100)
NOPs completed by age
range
−
−
−
−
−
−
Under 15
15-18 years
19-25 years
26-35 years
36-45 years
46-55 years
19
1,325
11,098
6,315
789
13
Data collected Between July 1, 2009 and July 31, 2011:
22
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
Notification of Pregnancy
Billing guidelines
–
Submit a claim to the appropriate managed
care entity to request reimbursement for
completion of a valid NOP form using
procedure code 99354 with modifier TH
–
Providers can submit a claim to receive $60 for
submission of a valid NOP form per pregnancy
–
There is no reimbursement when the NOP
form is
–
–
–
23
Submitted more than five calendar days from the date of service
A duplicate, there is already an NOP in the system for this woman’s pregnancy
Submitted for pregnancies beyond 29 weeks gestation
Presumptive Eligibility/Notification of Pregnancy Updates and Billing
October 2011
THIS CONCLUDES THE HP PORTION
OF THE PRESUMPTIVE ELIGIBILITY
PRESENTATION. THANK YOU FOR
YOU TIME AND ATTENTION!
QUESTIONS
Managed Care Entity Billing Requirements
and Updates: Presumptive Eligibility and
Notification of Pregnancy
Presented by Anthem Blue Cross and Blue Shield,
MDwise and Managed Health Services (MHS)
October 2011
25
Managed Care Entity Billing Requirements
and Updates
Welcome! Thank you for the compassion and dedication with which you
serve Hoosier Healthwise and Healthy Indiana Plan members .
Today we will share important information with you about billing
requirements, covered services and much more.
26
Presumptive Eligibility Covered Services
The Managed Care Entities (MCEs) follow the State’s guidelines
for covered services:
All services require pregnancy diagnosis and providers must adhere to MCE prior
authorization requirements. Covered pregnancy-related services are limited to
Hoosier Healthwise and include:
 Outpatient professional services, including mental health
 Outpatient services for other conditions that might complicate the pregnancy
 Lab Work
 Pharmacy
 Transportation for emergency and non-emergency services related to pregnancy
27
Package P Non-covered Services

Inpatient hospital stay

Labor and delivery

Post partum care

Newborn Services

Hospice

Long term care

Abortion

Sterilization

Ectopic pregnancy

Hysterectomy

Abnormal products of
contraception

Family planning service
28
Presumptive Eligibility Billing Requirements –
All Managed Care Entities
General Claims Submission

The presumptive eligible (PE) member’s MCE is responsible for claims
payment.

Claim timeliness requirements still apply.

Standard claim forms and filing processes should be followed.

Claim submission guidelines may vary by MCE (refer to the MCE’s
website and/or claim companion guides).

Providers may also refer to Chapter 8 in the Indiana Heath Coverage
Provider Manual for billing instructions which can be found at
www.indianamedicaid.com/manual.

.
29
Presumptive Eligibility Billing Requirements –
All Managed Care Entities
General Claims Submission

Claims must be billed with the 550 PE RID during PE period and billed
with the standard Hoosier Healthwise RID during Package A or B periods.
The PE coverage period is time-limited and claims could deny for use of
wrong PE/RID number.

In the case of retroactive Medicaid coverage for the member, the Hoosier
Healthwise RID must be used.
30
Claim Resubmission Guidelines
Resubmitted claims need to be clearly marked as resubmissions per the MCE’s
billing guidelines:

Anthem: Providers have 60 days from the date of initial determination to
resubmit claims. Adjustments are processed within time frames set by
Indiana law.

MDwise: Providers should reference the MDwise Quick Contact Sheet at
www.mdwise.org at Contact Info or contact the member’s delivery system
claims department.
Reference the Extended Filing Limit Bulletin at www.mdwise.org ,
Announcements for claim filing limit information and FAQs.
31
Claim Resubmission Guidelines
Resubmitted Claims (continued)

MHS: Providers have 60 days from date of initial determination to resubmit
claims to MHS. Adjustments are processed within 30 days.

Please contact the responsible MCE for claim status questions.
32
Presumptive Eligibility
Billing Requirements - MHS
Eligibility Verification

MHS will utilize the Hewlett Packard (HP) Web interChange system to
verify eligibility on the date of determination until complete eligibility data
is received from HP. (Up to three days.)
Claim Submission

Providers must use standard claim forms for billing.

MHS follows the Centers for Medicare and Medicaid Services (CMS)
guidelines for claim information and completion of required fields.

MHS can process claims submitted electronically, by paper and via the web.
33
Presumptive Eligibility
Billing Requirements - MHS
Claims Submission (continued)

Electronic claim submission is preferred and allows for more timely
payment. (98% processed in 21 days.)

Submission deadline is 365 days from date of service for non-participating
providers and by contract otherwise.

Resubmitted claims must be received within 60 days from the initial
determination.

Claims appeal requests must be received within 60 days from the initial
determination.
34
Presumptive Eligibility
Billing Requirements - MHS
Out of Network Provider Billing
To process out-of-network claims, the following data is needed for the
RENDERING provider of service:

NPI Number, Taxonomy, ZIP plus 4

Tax ID

PE ID Number on Claim (if billed during PE period)

Medicaid RID for packages A or B under Hoosier Healthwise (HHW)
Note: W9 must be on file with MHS and provider must be on the HP daily
provider table for payment to be made by MHS.
35
Presumptive Eligibility
Billing Requirements - Anthem
Claim Submission

Submit Anthem claims with YRH prefix with appropriate PE “550” or
Medicaid RID number based on eligibility for date of service.

Allow for processing time: 21 days for electronic claims and 30 days for
paper claims.

Submit claims within 90 days to:
Attn: Claims
Anthem Blue Cross and Blue Shield
P.O. Box 10787
Atlanta, GA 30348
36
Presumptive Eligibility
Billing Requirements - Anthem
For more information, providers may reference Anthem’s Provider Operations
Manual by going to:

www.anthem.com

Under Other Anthem Websites, click on Providers

Under Providers │Spotlight, click on State Sponsored Plans – Indiana
Hoosier Healthwise and Healthy Indiana Plan

On the State Sponsored Plans landing page, click on the link, Indiana
Hoosier Healthwise and Healthy Indiana Plan (HIP)

Scroll down to the header, Provider Communications

Click on Provider Operations Manual and Important Updates
37
Presumptive Eligibility
Billing Requirements - Anthem
Out-of-Network Providers
To process out-of-network claims, the following data is needed for the
RENDERING provider of service:

NPI

Taxonomy

Tax ID

PE ID (550) for package P or Medicaid RID for packages A or B under
HHW

Filing limit is 365 days from the date of service
Note: W9 must be on file with Anthem and Provider must be on HP Daily
Provider Table for payment to be provided by Anthem.
38
Presumptive Eligibility
Billing Requirements - MDwise
Claim Submission

Providers are encouraged to submit their claims electronically.

In-network MDwise providers must submit claims to the delivery system
claims department where the member is assigned.

Providers should reference the MDwise Quick Contact Sheet at
www.mdwise.org at Contact Info or contact the applicable delivery systems for
specific instruction on electronic claims submission.
39
Presumptive Eligibility
Billing Requirements - MDwise
Claim Submission

Please note that all electronic claims must be submitted using the HIPAA
compliant transaction and codes sets.

Providers may submit paper claims to the applicable delivery system address
(see quick contact sheet). Note: Red claim forms should be utilized.

Reference the Extended Filing Limit Bulletin at www.mdwise.org ,
Announcements for claim filing limit information and FAQs.
40
Presumptive Eligibility
Billing Requirements - MDwise
Claim Filing Limits

In-network Providers
 Filing limit is 90 from date of service as of 1/1/2011

Out-of-network Providers
 Filing limit is 365 days from the date of service
Note: All providers are responsible for checking eligibility at the time of
each visit.
Please visit myMDwise Provider Portal at www.mdwise.org to verify
member’s PMP and delivery system. The provider portal is free!
41
Presumptive Eligibility
Billing Requirements - MDwise
Out-of-Network Providers

To process out-of-network claims, the following data is needed for the
rendering provider:
 NPI, taxonomy, zip plus 4
 Tax ID
 LPI (Medicaid ID preferred)
 PE ID number on claim (if billed during PE period) or Medicaid RID
for packages A or B under HHW
Note: W9 must be on file with MDwise and Provider must be on the
HP daily provider table for payment to be provided by MDwise.
42
Presumptive Eligibility
Billing Requirements - All MCEs
Retroactive Hoosier Healthwise Coverage

Non-covered PE services may become covered if member becomes fully
eligible for Package A or B.
 In most circumstances, the retroactive time period will be assigned back to
PE determination date.
 Some members may have retroactive coverage that goes back further than
the PE determination date. Claims periods of time prior to PE should be
billed to HP unless assigned to MCE.

Providers should track claim denials during PE period for future submission
should the women become enrolled in Package A or B.

When the member changes from Package P to Package A or B coverage, NEW
claims must be resubmitted to the responsible MCE using the Medicaid RID
only for retroactively covered Medicaid coverage.
43
MCE Prior Authorization Requirements
MHS

Prior authorization requirements for Package B HHW apply.

Prior authorization requests must be received within two days prior to the
planned date of service.

Requests can be submitted via FAX to 1-866-912-4252 or online at
www.mhsindiana.com.

Requests can also be made by calling 1-877-647-4U4U, prompt 2.
44
MCE Prior Authorization Requirements
MDwise

Providers should reference the MDwise Quick Contact Sheet at
www.mdwise.org at Contact Info or contact the member’s MDwise delivery
system for authorization requirements.
Anthem

Before services are provided, call the Utilization Management Department
at 1-866-408-7187.
Note: Please utilize the Universal Prior Authorization Form for all MCEs for all
PA requests with the exception of Behavioral Health services.
45
Full and Hold Panels
Primary Medical Physician Assignment
If the MCEs are not able to contact the member prior to their start date, they
will automatically assign the member to a PMP.
If the member is not satisfied with the provider selection they will be allowed to
change their PMP. (HHW only.)
Hoosier Healthwise (HHW)
If a member does not select a plan within 30 days, one will be assigned for
them. After 90 days, the member will be locked into the MCE for the remainder
of their enrollment period.
Note: If a member does not choose a PMP within their MCE, one will be
automatically assigned to the member by the MCE.
46
Full and Hold Panels
Primary Medical Physician Assignment (continued)
Note: If a PMP disenrolls from an MCE and goes to another MCE,
members WILL NOT automatically follow the PMP to the new MCE. The
members will have to call Maximus to request the change for just cause.
Hold Panel
If panel is on hold, the member will need to select a different provider
that has a open panel within the same network.

There is no auto assignment in PE. Members must select a PMP and MCE
to have PE coverage activated.

Member’s automatically follow their PMP when they are assigned to from
Package P to Package B.
47
Presumptive Eligibility Claims Tips
- All MCE’s
PE Top Denial Reasons and Solutions
Reason: Package P pregnancy diagnosis not on the claim form.
Solutions:

Anthem: Diagnosis code must be primary on the claim form.

MHS & MDwise: Diagnosis must be on the claim form.
Note: Reference IHCP Manual, Chapter 8, Section 4.
48
Presumptive Eligibility Claims Tips
- All MCE’s
PE Top Denial Reasons and Solutions

Member Not Eligible: Be sure to file with the appropriate PE “550” or
Medicaid RID number based on eligibility for the date of service. You need to
check eligibility via the Web interChange prior to services being rendered.
MDwise- Please utilize myMDwise Provider Portal at www.mdwise.org to
verify the member’s PMP and delivery system.
Anthem: Claims must have YRH prefix before PE “550” or Medicaid RID
number.
49
Presumptive Eligibility Claims Tips
- All MCE’s
PE Top Denial Reasons and Solutions (continued)

No Authorization on File: Please see MCE’s website for Prior Authorization
(PA) requirements and forms.
Note: Please utilize the Universal Prior Authorization Form for all PA requests
with the exception Behavioral Health services.

Duplicate claim/services: Allow appropriate time frame for claim payment .
Note: Reference IHCP Manual, Chapter 8, section 4.
50
Notification of Pregnancy
51
Importance of Notification of Pregnancy
The early identification of pregnant members is important to:

Help ensure better birth outcomes

Identify risk factors and high-risk pregnancies

Coordinate case management

Obtain referrals

Reduce the number of early deliveries

Reduce the number of pregnant women who smoke
Providers are reimbursed for submitting the Notice of Pregnancy (NOP) Form.
52
Notification of Pregnancy (NOP)
Billing Guidelines
CPT Code/Modifier Combination

99354 TH - * Note NOP is not covered for HIP members.

Reimbursement is $60

One per member, per pregnancy

Only permitted on successfully submitted, complete and timely NOPs
 Submit via Web interChange
 Pregnancy is 29 weeks or less
 Entered in Web interChange within 5 calendar days of date of
service
Note: Provider or provider designee should complete the NOP form.
53
Notification of Pregnancy (NOP)
Billing Guidelines
PE members will be in Web interChange the day following
approval of PE.

Providers must wait to enter NOP until the day after PE is
determined.

The same requirements for successful, complete, timely submission
of the NOP apply for PE women.
54
Notification of Pregnancy Top
Denial Reasons & Solutions - All MCE’s

NOP not filed timely: A valid NOP form must be submitted via
Web interChange within 5 calendar days of the date of service in
order to be reimbursed.

Duplicate NOP. Reimbursement for NOP submission limited to
one time per pregnancy.

Member is over 29 weeks gestation: The member must be less than
30 weeks gestation for the provider to be eligible for reimbursement.

Eligibility: Be sure to file with the appropriate PE “550” or
Medicaid RID number based on eligibility for the date of service.
55
Notification of Pregnancy Wrap Up
Provider Benefits
 NOP data used to support provider plan of care with services and
resources available through MCE’s according to case management
risk stratification guidelines developed by the State.
 Care and Case Management programs from MCE.
 Supplemental member education materials, services and phone
calls.

Assist provider in linking member to community resources.

Additional revenue source - $60 per NOP/member/pregnancy.
56
Notification of Pregnancy Wrap Up
Provider Benefits
 High Risk: A woman must have at least two medical risk factors in
her current pregnancy or an obstetrical history that places her at risk
for pre-term birth or poor pregnancy outcome .
 May receive additional antepartum care visits for high risk
pregnancies beyond the maximum 14 visits allowed for normal
pregnancy.
 Reimbursement of additional $10 per prenatal visit.
Note: Per Banner BR201134, In order for providers to received
additional visits and reimbursement they must submit an NOP.
57
Notification of Pregnancy Wrap Up
Member Benefits
 Access to educational materials.

Dedicated care or case management programs.

Opportunity for additional visits with provider if high risk.

Early referral and access to community resources.
58
Resources
–
–
–
–
–
–
IHCP Web site at www.indianamedicaid.com
E-mail: pehelp@fssa.in.gov
Presumptive Eligibility Bulletins
• BT200910 and BT200920
NOP Bulletins
• BT200914, BT200921, and BT200941
Presumptive Eligibility Provider Manual (Web, CD-ROM, or paper)
HP Customer Assistance
• Local (317) 655-3240
• All others 1-800-577-1278
59
Resources
–
Written Correspondence
•
–
P.O. Box 7263
Indianapolis, IN 46207-7263
Provider field consultant
– View a current map territory map and contact information online at
http://provider.indianamedicaid.com/contact-us/provider-relationsfield-consultants.aspx
60
Resources
Anthem- www.Anthem.com

State Sponsored Plans-Indiana Hoosier Healthwise

Phone: 1-866-408-6132
MDwise - www.MDwise.org

Phone: 800-356-1204
MHS- www.mhsindiana.com

Phone: 1-877-647-4U4U (4848)
Medicaid Fee Schedule

Indianamedicaid.com/fee schedule
61
Questions?
Thank You from your Managed Care Entities
62