October 2009 Medical Equipment Guidelines Claim Attachments and Denial Resolution Presented by EDS Provider Field Consultants

MEDICAL EQUIPMENT UPDATES 2/ OCTOBER 2009 Agenda Date of Service Provider Code Sets Capped Rental Repair and Replacement Billing the Member Rolling 12 Month Period Mail Order Incontinence, Ostomy, and Colostomy Supplies Claim Attachments Denials and Resolutions Helpful Tools Questions Welcome and Announcements

MEDICAL EQUIPMENT UPDATES 3/ OCTOBER 2009 Session Objectives Following this session, providers will be able to understand: –Medical Equipment Guidelines –Claim Attachment Process –Top Denials and Resolutions

MEDICAL EQUIPMENT UPDATES 4/ OCTOBER 2009 Medical Equipment Guidelines

MEDICAL EQUIPMENT UPDATES 5/ OCTOBER 2009 Date of Service The date of service is the date the equipment is delivered, not ordered For the IHCP to reimburse for medical equipment, the member must be eligible on the date of service (date of delivery)

MEDICAL EQUIPMENT UPDATES 6/ OCTOBER 2009 Provider Code Sets The IHCP established code sets to ensure appropriate reimbursement for medical equipment codes Providers must ensure that they are enrolled as the correct provider type and specialty –Type and specialty can be verified using the Provider Profile option on the Web interChange

MEDICAL EQUIPMENT UPDATES 7/ OCTOBER 2009 Provider Code Sets The durable medical equipment (DME) provider type is 25 and the following are provider specialties: –251 – Home medical equipment provider –250 – DME/Medical supply dealer –Enrolling in the 251 specialty does not cover services in the 250 specialty, and enrolling in the 250 specialty does not cover services in the 251 specialty  Page 5 of the paper Provider Enrollment form lists the primary specialty in box 39, the additional specialty can be hand written in the unassigned box to the right

MEDICAL EQUIPMENT UPDATES 8/ OCTOBER 2009 Capped Rental Certain procedure codes are limited to 15 months of continuous rental The IHCP evaluates requests from providers for approval of capped rental items –In long-term need situations, a decision may be made to classify the item as “purchase” instead of “rental” Continuous rental is defined as rental without interruption for a period of more than 60 days –A change in provider does not cause an interruption in the rental period A complete list of procedure codes for capped rental can be found in the Indiana Health Coverage Programs Provider Manual, Chapter 8, Section 4 The provider must service the item at no cost to the IHCP

MEDICAL EQUIPMENT UPDATES 9/ OCTOBER 2009 Capped Rental Centers for Medicare and Medicaid Services (CMS) changed the capped rental policy for DME The new policy states that the capped rental period is 13 months –After 13 months, the member owns the DME Medicare will pay for reasonable and necessary maintenance and service of the DME item –This policy change applies to DME items in which the first month of rental is on or after January 1, 2006 At this time, Medical Policy has not been directed to make changes to the IHCP’s capped rental policy

MEDICAL EQUIPMENT UPDATES 10/ OCTOBER 2009 Capped Rental Claims Submitted for Capped Rental Items The allowed charge is the lower of the 1993 Medicare rental fee schedule amount or the actual submitted charge The IHCP pays claims until the number of rental payments made reaches the capped rental number of 15 months When the 15 month rental period has been exhausted, the DME/HME equipment is considered purchased and becomes the property of OMPP Providers should base their decisions to rent or purchase DME or HME on the least expensive option available for the anticipated period of need

MEDICAL EQUIPMENT UPDATES 11/ OCTOBER 2009 Repair and Replacement Repair of purchased equipment may require prior authorization based on the Healthcare Common Procedure Coding System (HCPCS) codes The IHCP does not pay for repair of equipment still under warranty The IHCP does not authorize payment for repair necessitated by member misuse or abuse, whether intentional or unintentional The rental provider is responsible for repairs to rental equipment

MEDICAL EQUIPMENT UPDATES 12/ OCTOBER 2009 Repair and Replacement The IHCP does not cover payment for maintenance charges of properly functioning equipment The IHCP does not authorize replacement of medical equipment more than once every five years per member – More frequent replacement is allowed only if there is a change in the member’s medical needs that is documented in writing and significant enough to warrant a different type of equipment. Such requests require PA A long-term care (LTC) facility’s per diem rate includes repair costs for equipment

MEDICAL EQUIPMENT UPDATES 13/ OCTOBER 2009 Billing the Member The following circumstances are the only situations in which an IHCP provider may bill a member: –The service rendered is non-covered by the IHCP –The member has exceeded the program limitations for a particular service; for example, the services were denied prior authorization (PA) –Before receiving the service, the member must understand that the service is not covered under the IHCP, and the member is responsible for the charges associated with the service –A signed waiver must be maintained in the member’s record that the member voluntarily chose to receive a service that was not covered by IHCP

MEDICAL EQUIPMENT UPDATES 14/ OCTOBER 2009 Billing the Member “Medicaid-pending” individuals are responsible to pay the provider It is the patient’s responsibility to notify the provider of Medicaid approved status within 12 months of the date of service Providers may bill the patient if there is no notification of Medicaid eligibility within this time period Providers may also bill the member when the spend-down or a copay applies to the claim Spend-down – Look for ARC Code 178 on the remittance advice Copay – Look for ARC Code 3 on the remittance advice

MEDICAL EQUIPMENT UPDATES 15/ OCTOBER 2009 Rolling 12 Month Period Is not: –Based on a 12-month calendar year –Based on a fiscal year –Renewable on January 1 of each year Is: –Based on the first date that services are rendered by a particular provider –Renewable one unit at a time beginning 365 days after the date that services are rendered by a particular provider

MEDICAL EQUIPMENT UPDATES 16/ OCTOBER 2009 Mail Order Incontinence, Ostomy, and Colostomy Supplies Contracted Vendors Effective February 1, 2008, the OMPP contracted with three vendors to provide incontinence, ostomy, and urological supplies to fee-for-service members The three contracted vendors are: – Binson’s Home Health Care Center – Healthcare Products Delivery, Inc (HPD) – J & B Medical

MEDICAL EQUIPMENT UPDATES 17/ OCTOBER 2009 Members must obtain supplies via mail order –The contracted vendor may make other arrangements in emergency situations The contracted vendors began providing services February 1, 2008, with full implementation completed on June 1, 2008 A full listing of codes affected by this change is available in BT The annual maximum allowable reimbursement is $1,950 per member per rolling calendar year. Mail Order Incontinence, Ostomy, and Colostomy Supplies

MEDICAL EQUIPMENT UPDATES 18/ OCTOBER 2009 Mail Order Incontinence, Ostomy, and Colostomy Supplies The contracted vendor service applies to the Fee for Service and Care Select Programs Only paid Crossovers and TPL claims are excluded from the program –If Medicare or the TPL denies the claim, the services are limited to the 3 contracted vendors The following programs and claim types are not affected by the contract: –590 Program –Medical Review Team (MRT) –Pre-Admission Screening and Resident Review (PASRR) –Long Term Care (LTC) –Waiver Risk-based managed care (RBMC) members are excluded –Supplies for these members are billed to the appropriate managed care organization (MCO) Program Guidelines

MEDICAL EQUIPMENT UPDATES 19/ OCTOBER 2009 Nursing Assessment A needs assessment is part of the initial enrollment process Members receive a telephone call from a staff nurse or a questionnaire by mail The questionnaire gives the vendor additional information regarding the member’s supply needs Mail Order Incontinence, Ostomy and Colostomy Supplies

MEDICAL EQUIPMENT UPDATES 20/ OCTOBER 2009 Claim Attachments

MEDICAL EQUIPMENT UPDATES 21/ OCTOBER 2009 Claim Attachments

MEDICAL EQUIPMENT UPDATES 22/ OCTOBER 2009 Claim Attachments

MEDICAL EQUIPMENT UPDATES 23/ OCTOBER 2009 Claim Attachments Unique number assigned by provider Claim and document specific Each ACN may only be used one time Write “ACN #” and the assigned ACN on each page of documentation corresponding to that number Attachment Control Number (ACN)

MEDICAL EQUIPMENT UPDATES 24/ OCTOBER 2009 Claim Attachments Select the appropriate Report Type –Report Type describes the document being sent Transmission Code defaults to “BM” – by mail –Electronic and ed attachments are not accepted Report Type and Transmission Code

MEDICAL EQUIPMENT UPDATES 25/ OCTOBER 2009 Claim Attachments Attachment Control Cover Sheet

MEDICAL EQUIPMENT UPDATES 26/ OCTOBER 2009 Claim Attachments Available on IHCP home page, under Forms Complete cover sheet for each claim Include provider information Provide member ID List each ACN pertaining to specific attachment Indicate the number of pages of documentation submitted per attachment (not including the cover sheet) Mail cover sheet and supporting documentation to the appropriate P.O. Box (P.O. Box 7259) Attachment Control Cover Sheet

MEDICAL EQUIPMENT UPDATES 27/ OCTOBER 2009 Denials and Resolutions

MEDICAL EQUIPMENT UPDATES 28/ OCTOBER 2009 Denials and Resolution Denial: Edit 0593 – Medicare Denied Detail Cause: At least one detail submitted contains Medicare COB data resulting in a review of all detail COB data Resolution: Review to ensure COB data for detail in question does not contain all zeros or is missing Crossover claim that has Medicare denied detail along with covered detail should be adjusted to only include the covered detail. Submit non-covered detail on separate claim with Medicare EOB – this is not a crossover claim

MEDICAL EQUIPMENT UPDATES 29/ OCTOBER 2009 Denials and Resolution Denial: Edit 0558 – Co-Insurance and Deductible Missing Cause: Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim. Resolution: Compare the detail line(s) to the Medicare EOB and complete crossover information Medicare crossover claims can be submitted electronically using Web interChange The following header information is required for the claim to process: –Payer ID and Payer Name –TPL/Medicare Paid Amount –Subscriber Name, Primary ID, Relationship Code, Gender, DOB, and Claim Filing Code –If the Payer ID is a Medicare payer and the Claim Filing Code is MA or MB, the claim is considered to have crossover information Note: Obtain COB information, including Payer IDs from the HELP tab, Reference Materials on Web interChange

MEDICAL EQUIPMENT UPDATES 30/ OCTOBER 2009 Denials and Resolution Denial: Edit 4209 – Procedure Code/Modifier Combination Cause: No matching pricing segment for the procedure/modifier combination billed on the HCFA 1500 Claim form Resolution: Refer to the Provider Procedures Manual for the appropriate use of the modifiers TC, 26, RR, and NU. - Effective December 31, 2008, the Centers for Medicare & Medicaid Services (CMS) end-dated modifier RP – replacement and repair, as announced in provider bulletin BT200843, dated December 30, Verify the procedure code/modifier combination on the Fee Schedule on the IHCP home page

MEDICAL EQUIPMENT UPDATES 31/ OCTOBER 2009 Denial Edit 4021 – Procedure Code Vs Program Indicator Cause: Procedure code is not covered for the dates of service for the program billed Resolution: Verify the procedure code and program coverage on the Fee Schedule on the IHCP home page Denials and Resolution

MEDICAL EQUIPMENT UPDATES 32/ OCTOBER 2009 Denial: Edit Invalid Procedure Code Modifier Combination Cause: The modifier used is not compatible with the procedure code billed Resolution: Verify procedure code and modifier combination on the Fee Schedule on the IHCP home page Consult the IHCP Provider Manual Denials and Resolution

MEDICAL EQUIPMENT UPDATES 33/ OCTOBER 2009 Denial: Edit 6000 – Manual Pricing Required Resolution: Submit Manual Pricing –Invoice requirements Date Billed amount per unit (for example, box, case, and so forth) Calories (enteral feeding) Procedure code Member name Member ID number Itemization of repairs –Bulk Invoices – illustrate calculations specific to the member Denials and Resolution

MEDICAL EQUIPMENT UPDATES 34/ OCTOBER 2009 Denial: Edit 6000 – Manual Pricing Required Resolution: Submit Manual Pricing Denials and Resolution

MEDICAL EQUIPMENT UPDATES 35/ OCTOBER 2009 Denial: Edit 6000 – Manual Pricing Required Resolution: Submit Manual Pricing Denials and Resolution DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 4/27/09 ANYWHERE, INDIANA BILL TO: DME/HME SUPPLIES 200 STATE STREET ANYWHERE, INDIANA ITEM NUMBER/DESCRIPTION U/M QTY PRICE TOTAL EXTRA SET RT ANGLE HCPCS: B9998 5/BOX sets in a box - ordered 1 box 59.90/5 = each Member rid# Abe Lincoln **********CUSTOMER INVOICE – ORIGINAL*************

MEDICAL EQUIPMENT UPDATES 36/ OCTOBER 2009 Denial: Edit Dates of service not on P.A. master file. Cause: No Prior Authorization in IndianaAim Resolution: Verify the date of service and procedure code billed are correct on the requested P.A. Obtain amended/corrected P.A. if necessary Denials and Resolution

MEDICAL EQUIPMENT UPDATES 37/ OCTOBER 2009 Denial: Edit 0509 – Net Charge Out of Balance Cause: Claim totals do not balance to the net charge entered on the claim Resolution: TPL claims: the net charge on a paper claim form in field 30, should equal the total charge, field 28, less the TPL paid amount, field 29 Medicare Crossover claims: the total charge, field 28, and the net charge, field 30, should be the same Denials and Resolution

MEDICAL EQUIPMENT UPDATES 38/ OCTOBER 2009 Denial: Edit 2003 – Recipient Ineligible on Dates of Service Cause: Member is not eligible for IHCP services being billed Resolution: Verify member eligibility using Web interChange, AVR or Omni Verify the claim was sent to the appropriate billing entity –Fee for Service and Care Select to EDS –RBMC to the appropriate MCO Denials and Resolution

MEDICAL EQUIPMENT UPDATES 39/ OCTOBER 2009 Helpful Tools Avenues of Resolution IHCP Web site at IHCP Provider Manual (Web, CD-ROM, or paper) Customer Assistance – , or –(317) in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN Provider Relations Field Consultant –View a current territory map and contact information online at HCP Web site at

MEDICAL EQUIPMENT UPDATES 40/ OCTOBER 2009 Questions

MEDICAL EQUIPMENT UPDATES 41/ OCTOBER 2009 EDS and the EDS logo are registered trademarks of Hewlett-Packard Development Company, LP. HP is an equal opportunity employer and values the diversity of its people. © 2008 Hewlett-Packard Development Company, LP. EDS 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204