Rural Health Clinic Billing Tips Provider Reference Supplement HP Enterprise Services, Arkansas Title XIX Document Date: 5/12/2010 HP Enterprise Services Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, Arkansas 72201 (501) 374-6608 HP Enterprise Services and the HP Enterprise Services logo are registered trademarks of HP Enterprise Services. All other logos, trademarks or service marks used herein are the property of their respective owners. HP Enterprise Services is an equal opportunity employer and values the diversity of its people. © 2010 HP Enterprise Services. All rights reserved. Contents Introduction ..................................................................................................................... 5 Eligibility .......................................................................................................................... 6 Restricted aid categories .............................................................................................. 6 Quick Tips for Submitting Claims..................................................................................... 9 Correcting Common Billing Errors ................................................................................ 9 Rural Health Clinic Core Services .............................................................................. 10 Billing Instructions ...................................................................................................... 12 Revenue Codes ......................................................................................................... 12 Non-Payable Diagnosis Codes .................................................................................. 12 Family Planning ......................................................................................................... 13 EPSDT and ARKids First-B Medical Screenings ........................................................ 13 Diagnosis Codes not Covered for Beneficiaries under 21 .......................................... 15 National Place of Service Codes ................................................................................ 15 Benefit Limits ............................................................................................................. 16 Contact Information ....................................................................................................... 17 4 Arkansas Medicaid Rural Health Billing Tips Introduction This Billing Tips document serves as a training supplement for Arkansas Medicaid providers, but does not supersede official program documentation including: Arkansas Medicaid Provider Reference manuals, Official Notices and transmittal letters published by the Division of Medical Services and distributed by HP Enterprise Services. This document focuses on Arkansas Medicaid eligibility and billing issues and incorporates the following quick reference items for your convenience: Consolidated list of restricted aid categories Provider Electronic Solutions (PES) claims submission instructions Eligibility request details Claim status report details Rural Health Revenue Codes Rural Health Non Payable/Non Covered Diagnosis Codes Place of Service Codes Benefit Limits 5 Arkansas Medicaid Rural Health Billing Tips Eligibility Beneficiary eligibility for the Arkansas Medicaid program is determined at the Department of Human Services (DHS) county office. A beneficiary’s eligibility may begin and end on any day of any month. Because program eligibility is date specific, providers should check each beneficiary’s eligibility on the date of service and are encouraged to do so using one of the following tools: PES Arkansas Medicaid Direct Data Entry (DDE) website Both tools verify eligibility electronically for a specific date or range of dates, including retroactive eligibility for a year. For more information on eligibility, refer to Section I of the Arkansas Medicaid provider manual. Restricted aid categories Many providers ask a question that is closely related to eligibility: “Is there a list of aid categories that require a primary care physician?” The answer is no. Arkansas Medicaid’s managed-care program, ConnectCare, stipulates that every Medicaid beneficiary and Medicaid waiver participant must enroll with a primary care physician (PCP) unless he or she is specifically exempt from that requirement. See the following sections of your Arkansas Medicaid provider manual for more information: Section 171.000, which lists the groups of individuals who may not enroll with a PCP Section 176.000, which lists Medicaid covered services that do not require PCP referral 6 The table below lists and briefly describes restricted aid categories. Post it at your workstation to use as a convenient quick reference: Aid Category Restriction 01 ARKids First-B Beneficiaries may have co-payment requirements. (PCP Required) Beneficiaries may be ineligible for certain services (see the ARKids First-B provider manual for exclusions.) 03 CMS (Children’s Medical Services) All services must be prior authorized by the CMS office. Non-Medicaid (No PCP Required) 04 DDS (Developmental Disability Services) Non-Medicaid (NO PCP Required) DDS non-Medicaid provider ID numbers end with ‘86’. DDS non-Medicaid beneficiary ID numbers begin with ‘8888’. Only DDS non-Medicaid providers may bill for DDS non-Medicaid beneficiaries. DDS beneficiaries may be dually eligible and receive additional services in another category. *6 Medically Needy Exceptional Beneficiaries are eligible for a full range of benefits except nursing facility and personal care. (PCP Required) *7 Spend Down (No PCP Required) (PCP required for Breast Care, 07) 08 Tuberculosis (NO PCP Required) Beneficiaries must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. Note: Aid category 07 BCC has full benefits. Beneficiary coverage includes drugs, physician services, outpatient services, rural health clinic encounters. Federally Qualified Health Center (FQHC) and clinic visits for TBrelated services only. 7 Arkansas Medicaid Rural Health Billing Tips Aid Category Restriction *8 QMB (Qualified Medicare Beneficiary) Medicaid pays Medicare premiums, coinsurance and deductible. (No PCP Required) If the service provided is not a Medicare covered service, Medicaid will not pay for the service under the QMB policy. Note: Aid category 18 S has full benefits. 61 PW-PL (Pregnant Woman Infants and Children Poverty level) This category contains both pregnant women and children. Providers must use the last three-(3) digits of the Medicaid ID number to determine benefits. (No PCP Required For Pregnant Woman) When the last three (3) digits are in the 100 series (i.e., 101, 102, etc.), the beneficiary is eligible as an adult and is eligible for pregnancy-related services only. (PCP Required for the Infants and children) When the last three (3) digits are in the 200 series (i.e., 201, 202, etc.), the beneficiary is eligible as a child and receives a full range of Medicaid services. Note: 62 PW-PE (Pregnant Woman Presumptive Eligibility) Plan description “PW unborn ch-noster/FP cov” indicates there is no sterilization or family planning benefits for the expectant mother. A temporary aid category that pays for ambulatory, prenatal services only. (No PCP Required) 69 Women’s Health Wavier (No PCP Required) Medicaid pays for family planning preventative services only, such as birth control or counseling. A claim for a beneficiary in this category must contain both a family planning diagnosis code and a family planning procedure code. 58, 78, 88 SLIMB (Specified Low Income Medicare Beneficiary)(SMB) Medicaid pays only their Medicare premium. (No PCP Required) 8 Quick Tips for Submitting Claims This section outlines quick tips for Rural Health Clinic providers in Medicaid. These billing tips address some of the most common billing errors identified by the HP Enterprise Services Provider Assistance Center (PAC). Topics include the following: Correcting common billing errors Procedure code quick reference Rural Health Revenue Codes Non Payable Diagnosis Codes Non Covered Diagnosis Codes for Beneficiaries under 21 Place of Service Codes Benefit Limits Correcting Common Billing Errors Refer to the chart below to learn how to correct common billing errors that are associated with certain Explanation of Benefits (EOB) codes: EOB Code Error Method of Correction 263 and 267 Beneficiary is partially or totally ineligible for the DOS. Verify the beneficiary is eligible for all claim dates of service. Resubmit the claim/portion of the claim for the time of eligibility. 208 Beneficiary aid category 69 is limited to family planning services only. Verify that the original claim has a family planning diagnosis and procedure code. Correct and resubmit the claim. 252 Medicaid ID number submitted does not match patient’s name on Medicaid ID card. Verify eligibility through Medicaid’s electronic eligibility system and resubmit the claim with correct information. 469 or 470 Duplicate billing. Claim is identical to another claim for DOS, performing provider, procedure, TOS and price. Verify that the service is not a duplicate bill. Resubmit the corrected claim 103 Claim does not meet the timely filing requirements for Medicaid. Claims must be received by HP Enterprise Services within 365 days from the “To” DOS. Claims received 9 Arkansas Medicaid Rural Health Billing Tips EOB Code Error Method of Correction beyond this deadline will not be paid. 952 Service requires Primary Care Physician referral. Resubmit the claim with the corrected PCP information required for adjudication. 199 ARKids 1st B beneficiary is older than 18 years old. ARKids 1st B beneficiary’s eligibility ends on their 19th birthday. The “from” DOS cannot exceed the 19th birthday. Rural Health Clinic Core Services Rural Health Clinic core services are as follows: A. Professional services that are performed by a physician at the clinic or are performed away from the clinic by a physician whose agreement with the clinic provides that he or she will be paid by the clinic for such services; B. Services and supplies furnished “incident to” a physician’s professional services; C. Services of physician assistants, nurse practitioners, nurse midwives and specialized nurse practitioners. These non-physician professional services are covered when: 1. Furnished by a nurse practitioner, physician assistant, nurse midwife or specialized nurse practitioner who is employed by, or receives compensation from, the rural health clinic; 2. Furnished under the medical supervision of a physician; 3. Furnished in accordance with any medical orders for the care and treatment of a patient prepared by a physician; 4. They are a type that the nurse practitioner, physician assistant, nurse midwife or specialized nurse practitioner who furnished the service is legally permitted to perform by the state in which the service is provided and 5. They would be covered if furnished by a physician. D. Services and supplies that are furnished as an incident to professional services furnished by a nurse practitioner, physician assistant, nurse midwife or other specialized nurse practitioner and E. Visiting nurse services on a part-time or intermittent basis to home-bound patients (limited to areas in which there is a shortage of home health agencies). 1. For purposes of visiting nurse care, a home-bound patient is one who is permanently or temporarily confined to his or her place of residence because of a medical or health condition. Institutions, such as a hospital or nursing care facility, are not considered a patient’s residence. 10 2. A patient’s place of residence is where he or she lives, unless he or she is in an institution such as a nursing facility, hospital or intermediate care facility for the mentally retarded (ICF/MR). 11 Arkansas Medicaid Rural Health Billing Tips Billing Instructions Rural Health Clinics can bill on the following claim forms: 1. UB-04 claim form (used for most RHC billing) 2. CMS-1500 (used for billing well child visits) 3. DMS-694 Billing Procedures, EPSDT claim form (used for billing EPSDT screening) Revenue Codes RHCs may use only these revenue codes when billing. Code Description 520 Encounter—Independent Rural Health Clinic 521 Encounter—Provider-based Rural Health Clinic 524 Basic or Periodic Family Planning Visit—Independent Rural Health Clinic 525 Basic of Periodic Family Planning Visit—Provider-based Rural Health Clinic Non-Payable Diagnosis Codes The following ICD-9-CM diagnosis codes are non-payable. Code Description V57.1 Other physical therapy V57.2 Occupational therapy and vocational rehabilitation V57.3 Speech therapy V72.5 Radiological examination, not elsewhere classified V72.6 Laboratory examination 12 Family Planning Revenue Code Description Procedure Code Description Modifier 0524 Basic or Periodic Family Planning Visit Independent RHC 99401 Periodic Family Planning Visit U9 0524 Basic or Periodic Family Planning Visit Independent RHC 99402 Basic Family Planning Visit U9 0525 Basic or Periodic Family Planning Visit Provider-Based RHC 99401 Periodic Family Planning Visit U9 0525 Basic or Periodic Family Planning Visit Provider-Based RHC 99402 Basic Family Planning Visit U9 EPSDT and ARKids First-B Medical Screenings Revenue Code NA Description EPSDT Periodic Complete Medical Screen (New Patient) NA EPSDT Periodic Complete Medical Screen (New Patient) NA NA NA NA NA NA NA NA NA NA NA EPSDT Periodic Complete Medical Screen (New Patient) EPSDT Periodic Complete Medical Screen (New Patient) EPSDT Periodic Complete Medical Screen (New Patient) EPSDT Periodic Complete Medical Screen (New Foster Care Patient) EPSDT Periodic Complete Medical Screen (New Foster Care Patient) EPSDT Periodic Complete Medical Screen (New Foster Care Patient) EPSDT Periodic Complete Medical Screen (New Foster Care Patient) EPSDT Periodic Complete Medical Screen (New Foster Care Patient) ARKids Complete Medical Screen (New Patient) ARKids Complete Medical Screen (New Patient) ARKids Complete Medical Screen (New Patient) Procedure Code Mod #1 Mod #2 99381 EP U1 99382 EP U1 99383 EP U1 99384 EP U1 99385 EP U1 99381 EP H9 99382 EP H9 99383 EP H9 99384 EP H9 99385 EP H9 99381 99382 99383 13 Arkansas Medicaid Rural Health Billing Tips Revenue Code NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA Description ARKids Complete Medical Screen (New Patient) ARKids Complete Medical Screen (New Patient) EPSDT Periodic Complete Medical Screen (Established Patient) EPSDT Periodic Complete Medical Screen (Established Patient) EPSDT Periodic Complete Medical Screen (Established Patient) EPSDT Periodic Complete Medical Screen (Established Patient) EPSDT Periodic Complete Medical Screen (Established Patient) EPSDT Periodic Complete Medical Screen (Established Foster Care Patient) EPSDT Periodic Complete Medical Screen (Established Foster Care Patient) EPSDT Periodic Complete Medical Screen (Established Foster Care Patient) EPSDT Periodic Complete Medical Screen (Established Foster Care Patient) EPSDT Periodic Complete Medical Screen (Established Foster Care Patient) ARKids Complete Medical Screen (Established Patient) ARKids Complete Medical Screen (Established Patient) ARKids Complete Medical Screen (Established Patient) ARKids Complete Medical Screen (Established Patient) ARKids Complete Medical Screen (Established Patient) EPSDT Newborn Care/Screen in Hospital EPSDT Newborn Care/Screen in Hospital EPSDT Newborn Care/Screen in Hospital Newborn Care/Screen in Hospital Newborn Care/Screen in Hospital Newborn Care/Screen in Hospital Procedure Code Mod #1 Mod #2 99391 EP U2 99392 EP U2 99393 EP U2 99394 EP U2 99395 EP U2 99391 EP H9 99392 EP H9 99393 EP H9 99394 EP H9 99395 EP H9 EP EP EP UA UA UA UA UA UA 99384 99385 99391 99392 99393 99394 99395 99460 99461 99463 99460 99461 99463 14 Diagnosis Codes not Covered for Beneficiaries under 21 The following ICD-9-CM diagnosis codes are non-payable for beneficiaries under the age of 21. Refer to the Child Health Services (EPSDT) provider manual and the ARKids First-B provider manual for instructions regarding procedure and diagnosis coding on well childcare claims. Code Description V70.0 Routine general medical examination at a health care facility V70.3 Other medical examination for administrative purposes V70.5 Health examination of defined subpopulations V70.7 Examination for normal comparison or control in clinical research V70.9 Unspecified general medical examination V72.85 Other specified examination National Place of Service Codes Electronic and paper claims now require the same National Place of Service code. Place of Service POS Codes Inpatient Hospital 21 Outpatient Hospital 22 Doctor’s Office 11 Patient’s Home 12 Ambulatory Surgical Center 24 Day Care Facility or DDTCS Facility 99 Nursing Facility 32 Skilled Nursing Facility 31 Other Locations 99 Independent Laboratory 81 End Stage Renal Disease Treatment Facility 65 Emergency Room 23 Inpatient Psychiatric Facility 51 15 Arkansas Medicaid Rural Health Billing Tips Benefit Limits A. There is no RHC encounter benefit limit for Medicaid beneficiaries under the age of 21 in the Child Health Services (EPSDT) Program. B. A benefit limit of 12 visits per state fiscal year (SFY), July 1 through June 30, has been established for beneficiaries aged 21 and older. The following services are counted toward the 12 visits per SFY benefit limit. 1. Physician visits in the office, patient’s home or nursing facility 2. Certified nurse-midwife visits 3. RHC encounters 4. Medical services provided by a dentist 5. Medical services provided by an optometrist 6. Advanced nurse practitioner services Global obstetric fees are not counted against the 12-visit limit. Itemized obstetric office visits are counted in the limit. Extensions of the benefit limit will be considered for services beyond the established benefit limit when documentation verifies medical necessity. Refer to section 218.310 of the Rural Health Clinic provider for procedures for obtaining extension of benefits. 16 Contact Information Providers needing assistance on billing, enrollment or technical support should call HP Enterprise Services at one of the following assistance numbers: 1-800-457-4454 (outside of Little Rock but in-state) (501) 376-2211 (local or out-of-state) Depending on the type of assistance needed, follow the instructions in the phone system to reach the appropriate department. The provider assistance departments are: Provider Assistance Center - The provider assistance center is open weekdays 8 a.m. to 5 p.m. to assist providers with claim issues, billing questions and denials. EDI support center - The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software downloads and setup support, software training and data transmission failures. Medicaid Provider Enrollment - The Medicaid Provider Enrollment Unit is open weekdays 8 a.m. to 5 p.m. to assist providers with enrollment in the Arkansas Medicaid program, changing PCP caseloads and updating demographic information. HP Enterprise Services Provider Representatives - HP Enterprise Services Provider Representatives are available to visit your facility by appointment. They assist providers with billing issues, software delivery and setup, escalated issues and policy questions. See the Arkansas Medicaid website for a list of representatives by counties. Research Analyst - The PAC Research Analyst assist providers with escalated billing issues, claim appeals and special processing requests. See the Arkansas Medicaid website for contact information by county. 17