Texas Workers’ Compensation Paper Medical Billing Form Changes Effective April 1, 2014 Texas Department of Insurance, Division of Workers’ Compensation

Objectives Part 1 Amended 28 Texas Administrative Code (TAC) § Required Billing Forms/Formats New 1500 Health Insurance Claim Form Version 02/12 (CMS-1500) - professional services International Classification of Diseases (ICD)-9 and ICD-10 transition 2

Objectives Part 2 Medical Billing Process Part 3 Centers for Medicare and Medicaid Services (CMS) and Division of Workers’ Compensation (DWC) Resources 3

PART 1 28 TAC § Required Billing Forms/Formats

§133.10(a) requires electronic medical billing in accordance with § and § unless the health care provider or insurance carrier is exempt from the electronic billing process in accordance with §

28 TAC § Required Billing Forms/Formats The purpose of the amendments is to reflect the changes in the newly updated CMS-1500 adopted by CMS. Changes were made to other paper billing form requirements for the purpose of aligning § to other DWC rules. Amendment changes are applicable to certified network, political subdivision, and non-network claims – see § (a). 6

28 TAC Chapter 134 Benefits--Guidelines for Medical Services, Charges, and Payments The DWC medical reimbursement rules address when the most current reimbursement methodologies, models, values, and weights used by CMS are applicable with any modifications addressed in those rules. 7

The updated CMS-1500 was approved by Medicare in June The updated CMS-1500 accommodates ICD-9 and ICD-10. New CMS

28 TAC § Required Billing Forms/Formats Requirements before April 1, 2014  CMS-1500 v08/05  Field 1a - “ ” if no SS#  Field 11 - “unknown” if the claim number is not known  Field 14 - no qualifier required  Field 17 - no qualifier required  Field 21 - no indicator required Requirements beginning April 1, 2014  CMS-1500 v02/12  Field 1a - leave blank if no SS#  Field 11 - leave blank if the claim number is not known  Field 14 - qualifier 431 required  Field 17 - no qualifier required (clarification)  Field 21 - ICD-9 or ICD-10 indicator required 9

10 CMS-1500 v02/12 - Field 1a - leave blank if no SS# - Field 11 - leave blank if the claim number is not known

11 CMS v02/12 - Field 14 - qualifier 431 required - Field 17 - no qualifier required (clarification)

12 CMS-1500 v02/12 -Field 21 - ICD-9 or ICD-10 indicator required (depending on date of service) -Field 24 - changed from numeric to alpha

ICD  Dates of service before October 1, 2014 *  Indicator “9” (field 21)  3-5 characters in length  Approximately 13,000 codes  Lacks detail ICD-10 Diagnosis Codes  Dates of service on or after October 1, 2014 *  Indicator “0” (field 21)  3-7 characters in length  Approximately 68,000 codes  More specific 13 ICD-9 Diagnosis Codes * Transition currently set for October 1, 2014

28 TAC § Required Billing Forms/Formats (paper billing form instructions) Professional medical bills submitted before April 1, 2014: CMS-1500 Version 08/05 Professional medical bills submitted on or after April 1, 2014: CMS-1500 Version 02/12 Note: § generally applies to health care providers submitting paper medical bills. 14

28 TAC § Required Billing Forms/Formats (paper billing form instructions) Use the new CMS-1500 on or after April 1, 2014 for both: Professional medical bills submitted for the first time; and All requests for reconsideration. 15

Requirements before April 1, 2014  UB-04 (Institutional) Field 62 enter “unknown” if the claim number is not known Requirements beginning April 1, 2014  UB-04 (Institutional) Field 62 leave blank if the claim number is not known 16  DWC Form-066 (Pharmacy) Field 15 enter “unknown” if the claim number is not known  DWC Form-066 (Pharmacy) Field 15 leave blank if the claim number is not known  Dental form Field 15 enter “unknown” if the claim number is not known  Dental form Field 15 leave blank if the claim number is not known 28 TAC § Required Billing Forms/Formats

PART 2 Medical Billing Process

28 TAC § Medical Bill Submission by Health Care Provider A complete medical bill must be submitted within 95 days from the date of service, with some exceptions found in §133.20(b). Health care providers may correct and resubmit as a new bill an incomplete bill that has been returned by the insurance carrier in accordance with other billing requirements. 18

28 TAC § Reconsideration for Payment of Medical Bills If the health care provider is dissatisfied with the insurance carrier's final action on a medical bill, the health care provider may request that the insurance carrier reconsider its action. 19

28 TAC § Reconsideration for Payment of Medical Bills The request for reconsideration must be submitted: not later than 10 months from the date of service for retrospective denial Insurance carrier shall take final action on a reconsideration request: not later than 30 days of receiving a request reconsideration of a retrospective denial 20

Dispute versus Complaint Dispute Disagreement between system participants involving the entitlement to workers’ compensation benefits and the amount to be paid. Complaint Grievance in the course of a workers’ compensation claim about something that did not happen in accordance with the workers’ compensation laws or rules. 21

28 TAC §180.1 Filing a Complaint Complaint must be submitted in writing: On-line: By fax: By By mail: DWC 7551 Metro Center Dr., Suite 100 MS-603 Austin, Texas

Types of Disputes There are three types of disputes resolved through separate and distinct processes: Claim Related Disputes – Compensability, Extent of injury, Liability Medical Necessity Disputes Medical Fee Disputes 23

24 How do I know which dispute process to pursue? The reason(s) for denial of payment directs the dispute resolution process. CEL IRO MFDR Dispute Process?

Explanation of Benefits (EOB) 28 TAC § Medical Payments and Denials The paper form of an EOB must include: Claim adjustment reason code(s) that conforms to the standards described in § and § of this title if total amount paid does not equal total amount charged, and An explanation of the reason for reduction/denial 25 American National Standards Institute (ANSI) Claim Adjustment Reason Codes Washington Publishing Company

Medical Fee Disputes and Resolution Process 26 EOB claim adjustment code examples (not an exhaustive list) Type of dispute Form to use Resolved by Where to send Link to Resources and Requirements P12 - Workers’ Compensation jurisdictional fee schedule adjustment Precertification/ authorization exceeded. Medical Fee Dispute DWC Form -060 Medical Fee Dispute Resolution Request (MFDR) Medical Fee Dispute Resolution (MFDR) DWC – MFDR in Austin wc/wc/mfdr/index.html

28 TAC § MDR of Fee Disputes Non-network claims A request MDR of a fee dispute may be filed: Not later than one year after the date(s) of service in dispute. Not later than 60 days after the date the requestor receives the final decision, inclusive of all appeals, on a related compensability, extent of injury, or liability. 27

28 TAC § MDR of Fee Disputes Non-network claims A request MDR of a fee dispute may be filed: Not later than 60 days after the date the requestor received the final decision on medical necessity, inclusive of all appeals, related to the health care in dispute and for which the insurance carrier previously denied payment based on medical necessity. Not later than 60 days after the date of the receipt of a refund notice pursuant to a DWC audit or review. 28

PART 3 CMS and DWC Resources

Resources 30

Stay Current with CMS Staying current with changes in CMS policy is essential for health care providers and insurance carriers. It is easier to keep up with changes in Medicare if the health care provider focuses on the specific services that it provides, i.e. Physical Therapists look for Physical Therapy resources & changes, Hospitals look for Hospital resources & changes. 31

Medicare Biller Workers’ Compensation Biller A good resource for the workers’ compensation biller is the person who bills for Medicare. How would you bill Medicare? 32

Medicare Learning Network (MLN) catalog of products – A comprehensive listing of health care provider/service specific fact sheets Learning-Network- MLN/MLNProducts/downloads/MLNCatalog.pdf 33

34 Medicare Learning Network (MLN) catalog of products

CMS Home Page – Medicare home page for health care providers which includes links to the “home” pages by subject matter or by health care provider type. 35

36 CMS Home Page

CMS MLN Web-Based training – Includes how to sign-up for electronic mailing lists to keep up with changes Learning-Network MLN/MLNProducts/WebBasedTraining.html 37

38 CMS MLN Web-Based training

Novitas Outreach & Education Page – Includes webinars – Organized by Part A or Part B 1.Select Jurisdiction H 2.Select Outreach and Education 39

40 Novitas Outreach & Education Page

Medicare Claims Processing Manuals – Detailed payment polices related to coding, billing and reimbursement by health care provider type. Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs Items/CMS html?DLPage=1&DLSort=0&DLSortDir=asce ding 41

42 Medicare Claims Processing Manuals

CMS Transmittals and Corresponding MLN articles – Contains Transmittals intended for Medicare Administrative Contractors or policy experts for implementation of policies/changes applicable in Medicare. They also contain detailed changes to Medicare Claims Processing Manuals if needed for implementation (this is not always needed to implement a policy). – Contains any corresponding MLN articles which are intended for health care provider education/implementation of policies/changes applicable to Medicare Guidance/Guidance/Transmittals/2013-Transmittals.html 43

44 CMS Transmittals and Corresponding MLN articles

CMS Transmittal Transmittal R2842CP Form CMS-1500 Instructions: Revised for Form Version 02/12 Guidance/Guidance/Transmittals/2013-Transmittals Items/R2842CP.html 45

46 CMS Transmittal

CMS MLN Article MLN MM8509 CMS 1500 Claim Form Instructions: Revised for Form Version 02/12 Learning-Network MLN/MLNMattersArticles/Downloads/MM8509.pdf 47

CMS MLN Article 48

CMS Information about ICD-10 - ICD-10 Introduction fact sheet and FAQs - Sign up for CMS ICD-10 Industry Updates 49

CMS Information about ICD-10 50

National Uniform Claim Committee 02/ Claim Form w=article&id=186&Itemid=138 51

National Uniform Claim Committee 02/ Claim Form 52

DWC Customer Service

Call DWC Comp Connection opt. 3 54

DWC Health Care Provider Resources 55

DWC eNews 56

DWC eNews 57

DWC Resources Visit the DWC Health Care Provider Web Page Subscribe to eNews to receive news about various Texas Department of Insurance issues Send question by 58

Learned Objectives Part I Amended 28 TAC § Required Billing Forms/Formats New CMS-1500 (professional services) ICD-9 and ICD-10 transition Part II Medical Billing Process Part III CMS and DWC Resources 59

Any Questions?