April 2009 Prenatal Care Coordination Billing Presented by the EDS Provider Relations Field Consultants

PRENATAL CARE COORDINATION BILLING 2/ April 2009 IHCP Provider Enrollment Provider Updates Member Eligibility Benefit Packages Care Coordination Services Notice of Pregnancy Presumptive Eligibility Managed Care Welcome and Announcements Agenda Care Management Organizations Billing Remittance Advice Adjustments Paper Claim Filing Top Five Denials Helpful Tools Questions

PRENATAL CARE COORDINATION BILLING 3/ April 2009 Indiana Health Coverage Programs Traditional Medicaid 590 Fee-for-Service

PRENATAL CARE COORDINATION BILLING 4/ April 2009 New Provider Enrollment Enrollment forms are in electronic format on the Web by using All forms may be filled out online and the information submitted electronically All pages requiring original signatures and tax information (W-9s) must be mailed to EDS Provider Enrollment after completing the online application Enrolling online provides the following advantages: –Quicker provider enrollment –Complete and accurate information –Easier enrollment

PRENATAL CARE COORDINATION BILLING 5/ April 2009 Provider Enrollment Step 1: Begin at indianamedicaid.com

PRENATAL CARE COORDINATION BILLING 6/ April 2009 Indiana Health Coverage Programs (IHCP) Web site at Provider Enrollment helpline at Provider Enrollment Application Provider Enrollment

PRENATAL CARE COORDINATION BILLING 7/ April 2009 Online Enrollment

PRENATAL CARE COORDINATION BILLING 8/ April 2009 Download the Provider Enrollment Application: –Visit –Go to the Provider Services tab –Choose Provider Enrollment from the drop-down list –Access the link titled Enroll a New Provider in the IHCP –Print the Provider Enrollment Application and an IRS W-9 Form Complete the enrollment application (original signatures are required) Avoid having your application returned –Call if you have questions about the enrollment forms Process Provider Enrollment

PRENATAL CARE COORDINATION BILLING 9/ April 2009 IHCP reimbursement is available for the following practitioners who provide care coordination services to eligible pregnant women in the IHCP: –State-licensed physician –State-licensed registered nurse –State-certified social worker or a social worker with a baccalaureate or master’s degree from a school accredited by the Council on Social Work Education –Dietician registered with the Commission on Dietetic Registration of the American Dietetic Association –Community health worker working under the supervision of one of the professionals listed above Provider Enrollment Requirements Provider Enrollment

PRENATAL CARE COORDINATION BILLING 10/ April 2009 The enrollment packet must include: –Completed Provider Enrollment Application (with all applicable schedules) –Completed IRS W-9 Form –Waiver Approval Letter certifying the waiver services that the provider is approved to perform Mail to: EDS Provider Enrollment P.O. Box 7263 Indianapolis, IN Mailing the Application Provider Enrollment

PRENATAL CARE COORDINATION BILLING 11/ April 2009 Provider Updates Updates to the following information must be submitted to the EDS Provider Enrollment Unit: –Address changes (home office, mail-to, pay-to, and service location) –Telephone number changes –Banking information changes (if enrolled in electronic funds transfer) Requests for changes must be submitted using the EDS Provider Update Form available at

PRENATAL CARE COORDINATION BILLING 12/ April 2009 Members must be enrolled in the IHCP and have pregnancies that are at risk for low birth weight or poor pregnancy outcome to be eligible for the IHCP to pay for care coordination services Each member has a Hoosier Health Card used for identification Viewing a Hoosier Health Card alone does not verify eligibility Who is Eligible? Member Eligibility

PRENATAL CARE COORDINATION BILLING 13/ April 2009 Providers must verify eligibility on the date of service Providers who fail to verify eligibility are at risk of their claims being denied due to member ineligibility or coverage limitations Verifying Eligibility Member Eligibility

PRENATAL CARE COORDINATION BILLING 14/ April 2009 Three Eligibility Verification Systems (EVS) are available: Automated Voice Response (AVR) – , or –(317) , Indianapolis area Omni swipe card terminal device Web interChange How to Verify Member Eligibility

PRENATAL CARE COORDINATION BILLING 15/ April 2009 AVR provides the following: Member eligibility verification Benefit limits Prior authorization Claim status Check write Contact AVR at (317) in the Indianapolis local area or EVS Using the Telephone Automated Voice Response System

PRENATAL CARE COORDINATION BILLING 16/ April 2009 Is cost-effective for high-volume providers Uses plastic Hoosier Health card Allows manual entry Prints two-ply forms Requires upgrade for benefit limit information (refer to IHCP provider bulletin BT200711) See Chapter 3 of the IHCP Provider Manual for more information EVS Card Reading Device Omni

PRENATAL CARE COORDINATION BILLING 17/ April 2009 The following is available through Web interChange: Member information available by member ID, Social Security number (SSN), Medicare number, or name and DOB Division of Family Resources (DFR) information Detailed third-party liability (TPL) information Online TPL update requests Web interChange is accessible via EVS Using the Internet Web interChange

PRENATAL CARE COORDINATION BILLING 18/ April 2009 Web interChange Eligibility

PRENATAL CARE COORDINATION BILLING 19/ April 2009 Benefit Packages Benefit PackageCoverage Package A – Standard Plan  Encompasses the full array of Indiana Health Coverage Programs (IHCP) benefits for children, low-income families, and some pregnant women enrolled in the Hoosier Healthwise Program. Package B  Coverage is limited to pregnancy-related and urgent care services for some pregnant women. Package C  Limited coverage (including preventive, primary, and acute care services) for children under 19 years old enrolled in the Children’s Health Insurance Plan ( CHIP ).

PRENATAL CARE COORDINATION BILLING 20/ April 2009 Diagnosis Code: V68.9 Procedure Codes: H1000 – Initial Assessment (One per pregnancy) H1004 – Reassessment (One per trimester) – Home visit for newborn care and assessment Diagnosis and Procedure Codes Care Coordination Services

PRENATAL CARE COORDINATION BILLING 21/ April 2009 A0160 U1 – Two round trips per initial assessment A0160 U2 – Two round trips per assessment A0160 – One round trip per postpartum assessment Procedure Codes for Mileage Care Coordination Services

PRENATAL CARE COORDINATION BILLING 22/ April 2009 Prenatal Care Coordination Forms Risk Assessment Form: –Must be kept in the member’s record to substantiate services beyond the initial assessment Combined Assessment Form –Used for one initial assessment and follow-up –One reassessment and follow-up per trimester occurring after the initial assessment –One postpartum assessment Care Coordination Outcome Report –Send the Outcome Report to the Indiana State Department of Health (ISDH) regardless of when the patient has finished care

PRENATAL CARE COORDINATION BILLING 23/ April 2009 Following up to verify or reschedule appointments Locating services sources Making appointments Arranging transportation Making home visits (including the postpartum home visit) Referring member to the Social Security agency Performing follow-up activities to ensure services were received Prenatal Care Coordination Services Care Coordination Services

PRENATAL CARE COORDINATION BILLING 24/ April 2009 Case management services for pregnant women: Active, ongoing process of assisting the member to identify, access, and use community resources and coordinate services to meet individual needs Third Party Liability edit overrides for care coordination services Providers not required to file for reimbursement from other insurers Care Coordination Services Prenatal Care Coordination Services

PRENATAL CARE COORDINATION BILLING 25/ April 2009 Notice of Pregnancy – Effective July 1, 2009 The Office of Medicaid Policy and Planning (OMPP), managed care organizations (MCOs), the Indiana State Department of Health (ISDH) and other Medicaid stakeholders worked jointly to develop a universal assessment for pregnant women to capture: 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 - HTN, Diabetes) Current Medications Mental Health History and Current Conditions Substance Abuse/Use History Tobacco Use History Social Risk Factors Needed Referrals

PRENATAL CARE COORDINATION BILLING 26/ April 2009 Reimbursement of $60 to the physician/clinic per Notice of Pregnancy (NOP) submitted within five calendar days of the prenatal visit Other details: –Provider must submit a claim to be reimbursed for NOP form submission –NOP form submission may be billed one time per member, per pregnancy –Providers submit the NOP form via Web interChange –Providers bill for submission of the NOP form using procedure code with modifier TH Note: Procedure code and reimbursement available July 1, 2009 Reimbursement Notification of Pregnancy

PRENATAL CARE COORDINATION BILLING 27/ April 2009 Print a hard copy and complete during the exam Enter information electronically from hard copy or Enter the information electronically during the exam To qualify for payment, provider must: –Submit NOP within five calendar days from Date of Service, and –Complete NOP prior to 30 weeks gestation Completing the NOP Notification of Pregnancy

PRENATAL CARE COORDINATION BILLING 28/ April 2009 Notification of Pregnancy Click on the appropriate responses. Then click “Next” Completing the NOP

PRENATAL CARE COORDINATION BILLING 29/ April 2009 Notification of Pregnancy Data is sent to the member’s MCO MCOs provide additional support services (for example, nurse case management, home visits) depending on needs of member MCO can also help with coordination between the physician’s office and member MCO will also coordinate with the prenatal care coordinator The OMPP will use the data to monitor outcomes of births and to develop programming that better meets the needs of pregnant women in Medicaid

PRENATAL CARE COORDINATION BILLING 30/ April 2009 Presumptive Eligibility – Effective July 1, 2009 What is presumptive eligibility? –A period of time during which a pregnant woman, who has been determined by a qualified provider 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

PRENATAL CARE COORDINATION BILLING 31/ April 2009 To be eligible for Presumptive Eligibility (PE), a pregnant woman must: –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 non-citizen –Not be currently incarcerated –Have gross family income less than 200 percent of the federal poverty level Who is Eligible? Presumptive Eligibility

PRENATAL CARE COORDINATION BILLING 32/ April 2009 Many of the requirements for qualified providers are mandated by Federal Medicaid regulations: 1.Must be enrolled in Medicaid 2.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 3.Must be trained and certified by the State (or designee) to perform PE functions State-specific requirements include: 1.Must be able to verify pregnancy via a professionally administered pregnancy test 2.Must have Internet, telephone, printer, and fax access that is available to facilitate the PE and Medicaid application process 3.Must have Administrator access to Web interChange Complete the Administrator Request Form to set up an administrator Presumptive Eligibility Who Can Be a Qualified Provider?

PRENATAL CARE COORDINATION BILLING 33/ April 2009 Qualified providers (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 Who Can Be a Qualified Provider? Presumptive Eligibility

PRENATAL CARE COORDINATION BILLING 34/ April 2009 How the PE Process Works Check for any existing Medicaid coverage using the Eligibility Inquiry feature of Web interChange QP professionally administers a pregnancy test or accepts pregnancy test administered by another professional to determine if the patient is pregnant –Over-the-counter pregnancy tests cannot be used to determine pregnancy for PE If the patient is not covered by Medicaid, a QP-trained staff member accesses the PE Application by clicking the “PE Application for Pregnant Women” button (Step 1) –The PE Application window is available during the following business hours: Monday-Friday – 8 a.m. to 6 p.m. (Eastern time) Saturday – 8 a.m. to Noon (Eastern time) Note: If applicable, the non-QP refers the patient to a QP to complete the PE application process

PRENATAL CARE COORDINATION BILLING 35/ April 2009 How the PE Process Works QP enters the following information based on responses from the patient: –Applicant name, Social Security number, date of birth, home address, mailing address, contact telephone, gender, marital status, gross income, family size, and race QP also answers “yes” or “no” to the following: –Indiana residency, incarceration status, verification of pregnancy, U.S. citizenship, and whether or not an application for Medicaid/Hoosier Healthwise is pending Applicant responses are to be accepted by the QP without asking for verification documents –If presented, verification documents may be faxed with the Hoosier Healthwise application

PRENATAL CARE COORDINATION BILLING 36/ April 2009 How the PE Process Works QP provides the woman with access to a telephone to contact the enrollment broker (MAXIMUS) MAXIMUS explains the selection process to the woman and assists her to select a primary medical provider (PMP) and MCO QP ensures the woman’s PMP and MCO choices are written on her PE determination notice for reference MAXIMUS activates the patient’s PE number If, on that day, the woman fails to contact MAXIMUS to make her PMP and MCO selections, her PE eligibility will terminate that day and the QP will receive no reimbursement for prenatal services

PRENATAL CARE COORDINATION BILLING 37/ April 2009 How the PE Process Works Applicant is responsible for reviewing the printed Hoosier Healthwise application and providing additional responses as appropriate QP ensures the patient signs the Hoosier Healthwise application and faxes it to the Division of Family Resources (DFR). QP also faxes a statement signed by the physician or nurse indicating the woman is pregnant and the date the pregnancy began Modernized counties: –Direct questions about the Hoosier Healthwise application to the DFR Document Center at –Fax is sent to the DFR Document Center at –Direct questions about the Hoosier Healthwise application to the local DFR office –At click “Where Do I Apply,” then click on woman’s county of residence to locate county DFR telephone and fax informationhttp:// –Fax is sent to the county DFR office

PRENATAL CARE COORDINATION BILLING 38/ April 2009 How the PE Process Works PE Considerations: –The above functions occur on the same day –There is no PE coverage if the woman, who has been determined to be presumptively eligible does not select a PMP and MCO with the Enrollment Broker –Women are eligible for PE only one time per pregnancy –QP enrollment activities are performed on a voluntary basis –QPs should allow approximately 15 minutes to complete PE functions

PRENATAL CARE COORDINATION BILLING 39/ April 2009 Prenatal care coordinators can: –Encourage clinics to become qualified providers –Perform outreach to physicians to accept women with Presumptive Eligibility –Refer pregnant women to qualified providers for eligibility determination –Assist women with follow-up of Medicaid Application process Presumptive Eligibility Process How You Can Help

PRENATAL CARE COORDINATION BILLING 40/ April 2009 Helpful Tools – PE and NOP Bulletin about PE is scheduled for late April 2009 Training of qualified providers is scheduled to begin in mid-May 2009 Bulletin about NOP is scheduled for mid-May 2009 Both programs are scheduled to begin July 1, 2009 Questions about PE and NOP can be directed to the Office of Medicaid Policy and Planning:

PRENATAL CARE COORDINATION BILLING 41/ April 2009 MCOs contracted in Hoosier Healthwise risk- based managed care (RBMC): Anthem Managed Health Services (MHS) MDwise ADVANTAGE administers PrimeStep primary care case management (PCCM) and Care Select , Option 3 Managed Care in the IHCP Managed Care

PRENATAL CARE COORDINATION BILLING 42/ April 2009 Care Management Organizations Two health plans were selected to function as care management organizations (CMOs) for the Care Select program –ADVANTAGE Health Solutions SM –MDwise MDwise also serves as one of Indiana’s three Hoosier Healthwise MCOs

PRENATAL CARE COORDINATION BILLING 43/ April 2009 Providers may not collect from a member or family member any portion of the covered service that is not reimbursed by the IHCP, except for copayments on transportation and pharmacy services and any member liability payment authorized by law Participating providers must accept the Medicaid determination of payment in full Billing the IHCP Member for Noncovered Services Billing

PRENATAL CARE COORDINATION BILLING 44/ April 2009 You may only bill for authorized services. For services to be authorized they must: Meet the needs of the member Be a noncovered service by the IHCP or a covered service, which the member has exceeded the program limitations The member must understand, before receiving services, that they will be financially responsible Provider must maintain documentation showing the member accepted responsibility for the charges Billing the IHCP Member, Exceptions Billing

PRENATAL CARE COORDINATION BILLING 45/ April 2009 Remittance Advices (RAs) provide information about claims processing and financial activity related to reimbursement –RAs contain internal control numbers (ICNs) with detail-level information –RAs give detail status (paid or denied) –RAs give payment amount See the IHCP Provider Manual, Chapter 12, for more details Statement with Claims Processing Information Remittance Advice

PRENATAL CARE COORDINATION BILLING 46/ April 2009 The ICN is a 13-digit number assigned to each claim The region tells how the claim was submitted – 20 – electronic with no attachments – 21 – electronic with attachments – 10 – paper with no attachments – 11 – paper with attachments – 50 – voids/replacements – noncheck-related Region Year Julian Date Batch Range Sequence Internal Control Number Adjudicated Claim Information

PRENATAL CARE COORDINATION BILLING 47/ April 2009 “Replacement” is a HIPAA-approved term used to describe the correction of a claim that has already been submitted Replacements can be performed on paid and denied claims Denied details can be replaced or billed as a new claim To avoid unintentional recoupments, submit paper adjustments for claims finalized more than one year “Void” is the term used to describe the deletion of an entire claim Voids can be performed on paid claims only Voids and replacements can be performed to correct incorrect or partial payment, including zero dollar amount Note: Paper replacements can only be processed on paid claims Voids and Replacements Claim Adjustments

PRENATAL CARE COORDINATION BILLING 48/ April 2009 Use the approved version of the CMS-1500 claim form Do not use staples or paper clips Verify that the claim form is signed, or complete the Attestation for Signature on File Review the RA closely Helpful Hints Paper Claim Filing

PRENATAL CARE COORDINATION BILLING 49/ April 2009 Top Five Denials for Care Coordination Services 1008 – Rendering provider must have an individual number 2006 – Members are eligible for emergency services only 2017 – Recipient ineligible on date(s) of service 0512 – Claim past filing limit 9018 – No payment made spend-down is > than IHCP allowed

PRENATAL CARE COORDINATION BILLING 50/ April 2009 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 Indiana State Department of Health –(317) Avenues of Resolution Helpful Tools

PRENATAL CARE COORDINATION BILLING 51/ April 2009 Questions

PRENATAL CARE COORDINATION BILLING 52/ April 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. © 2009 Hewlett-Packard Development Company, LP. EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204