1. IHCP Rural Health Clinic Billing
HP Provider Relations/June 2014

2. Agenda RHC Basics Claim Inquiry Common Claim Denials
Where to bill claims
Third Party Liability
Helpful Tools

3. Objectives Participants will understand: The basics of RHC
How to bill for services
How to read and resolve claim issues
Who to bill for services

4. RHC Basics

5. The Beginning
RHC programs were established to address underserved rural communities and to reduce patient load on hospital emergency rooms
Any area that is not in a U.S. Census-designated “urbanized area” (50,000 population)
A FQHC may be in an urban area
Must be in a designated shortage area
Federally designated Health Professional Shortage Area (HPSA)
Federally designated Medically Underserved Area (MUA)
State governor designated underserved area

6. Enrollment Basics
Providers should forward the Centers for Medicare & Medicaid Services (CMS) letter with enrollment application
This letter grants RHC status
Submit proper financial documents to Myers and Stauffer (rate- setting contractor) to establish rate
Indiana State Department of Health sends Certification and Transmittal (C&T) to HP
Providers are enrolled as a group, with rendering providers linked
Provider Type 08
Specialty Type 081-RHC

7. Service Coverage
According to 405 IAC , IHCP reimbursement is available to RHCs and FQHCs for services provided by the following providers:
• Physician
• Physician assistant
• Nurse practitioner
• Clinical psychologist
• Clinical social worker
• Dentist
• Dental hygienist
• Podiatrist
• Optometrist

8. Service Definition
A visit is a face-to-face encounter between the patient and provider
Multiple services performed during the same visit for the same or related diagnosis are considered a single encounter
Multiple visits that occur within the same 24-hour period for the same diagnosis are considered a single encounter

9. Eligibility Verification
Verification of eligibility before every service is strongly encourage
The best way to verify eligibility is Web interChange
Other ways to verify eligibility
Automated Voice Response ( AVR ) system

10. Reimbursement AIM processing for PPS methodology began April 1, 2003
Must use Healthcare Common Procedure Coding System (HCPCS) Level III codes, including T1015 – clinic, visit/encounter, all-inclusive, and Level I and II codes
Provider receives a facility-specific PPS rate determined by Myers and Stauffer

11. Place of Service Submit claims with place of service codes:
11 – office
12 – home
31 – skilled nursing facility
32 – nursing facility
72 – RHC
Submit claims with T1015 and the applicable HCPCS/Current Procedural Terminology (CPT) code
The HCPCS/CPT code will deny with error code 6096 –Code not payable according to PPS methodology
The encounter rate T1015 is reimbursed according to the rate established by Myers and Stauffer

12. Service Allowance
The IHCP only allows one encounter per IHCP member, per provider, per day, unless the diagnosis code differs
Providers can submit valid encounters with differing diagnosis codes to HP for manual processing
Documentation should be submitted through Written Correspondence
Documentation requirements are:
Documentation in writing from the medical record that supports the medical reasons for the additional visit
- This documentation includes presenting symptoms or reasons for the visit, onset of symptoms, and treatment rendered.
Documentation that the diagnosis for each encounter is different

13. T1015 Exempt Place of Service Codes
Hospital services (place of service 20-26) are not considered RHC, and the T1015 encounter code is not required
20 Urgent Care Facility
21 Inpatient Hospital
22 Outpatient Hospital
23 Emergency Room
24 Ambulatory Surgical Center
25 Birthing Center
26 Military Treatment Facility
Dental services are billed with Current Dental Terminology (CDT) codes on dental claim forms

14. Claim Inquiry

15. Claim Inquiry

16. Claim Inquiry
National Provider Identifier (NPI) or LPI will automatically populate
For multiple locations – choose appropriate service location
Member recipient identification number (RID)
From and through date of service of specific claim
Search by date of service (DOS)
Why not search by internal control number (ICN)?
ICN will only give information on one specific claim
Review all claim submissions and denial reasons
Use paid claim (if applicable) for corrections
Adjust the paid claim or void and start over
Note: Documentation submitted with original claim must also be submitted with current claim. This applies to paper and electronic claims.

17. Claim Inquiry

18. Claim Inquiry

19. Claim Inquiry Claim submission information is displayed
Choose the appropriate claim to work with
i.e. most recent ICN or paid claim
Click on the ICN
Choose
Scroll to the bottom of the claim
Adjustment reason codes (ARCS)
Health Insurance Portability and Accountability Act of (HIPAA) required fields – not the reason detail denied
REMARKS
HIPAA required fields – not the reason detail denied
Provide spend down information

20. Claim Inquiry CLAIM STATUS INFORMATION Provides detailed information
disposition of each EOB (explanation of benefits) code – LOOK FOR THE “D”
H/D – the header or detail level
WHY DID THE CLAIM/DETAIL LINE DENY
description

21. Common claim denials

22. Common Denials
Recipient ineligible on date of service – due to enrollment in a Managed Care Entity
Resolution:
VERIFY MEMBER ELIGIBILITY
Understand the eligibility information
Submit claim to the appropriate entity

23. Common Denials
Recipient ineligible on date of service

24. Common Denials 4121 – T1015 must be billed with procedure code
Resolution:
Copy the claim in Web interChange
Add T1015 detail line
Save detail
Submit claim.

25. Common Denials 0558 - Coinsurance and deductible amount missing
Claim submitted has no coinsurance and deductible amount indicating that this is not a crossover claim
Resolution:
Verify claim is a crossover claim
Submit claim with appropriate crossover information
Primary explanation of benefits (EOB) is not required if payment has been made
If claim is not crossover
Submit as Medicaid primary
Include supporting EOB documentation if applicable

26. Medicare and Replacement Plans

27. Medicare and Replacement Plans

28. Common Denials Crossover Claim Information
Payer ID = REPLACEMENT PLAN OR MEDICARE PAYER ID
Payer Name = Wisconsin Physician Services (Traditional Medicare) or
Replacement Plan name in the Payer Name Field
Medicare Paid Amount = The total amount paid by Medicare for the claim
Subscriber Name = Name of policy holder for primary insurance
Primary ID = ID number of the primary insurance (Medicare or Replacement Plan)
Relationship Code = 18 (self)
Claim Filing Code = 16 (Replacement Plan) or MB (Traditional Medicare)
Click Save Benefits at the bottom of the screen
Click Save and Close at the top of the screen
Note: Obtain coordination of benefits (COB) information from the HELP tab, Reference Materials on Web interChange

29. Common Denials Information required in Field 22
Coinsurance/Deductible Information
Medicare Payment Information

30. Third Party Considerations

31. Third-Party Liability Considerations
All third-party liability (TPL), patient liability, and copayments continue to apply as appropriate
Allowable Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) and pregnancy services provided during an encounter continue to bypass TPL edits
Medicare crossover reimbursement methodology is excluded from PPS logic
T1015 not necessary on crossover claims
Medicaid reimburses deductible and coinsurance, even if Medicare payment greater than PPS rate
TPL payment information for paper claims:
CMS-1500 – Block 29
Dental Claim – Block 35
UB-04 – Block 54 B

32. Who pays my claim?

33. Care Select
Claims submitted for members in Care Select no longer require primary medical provider (PMP) authorization if the service was not provided by the PMP
Self-referral services provided at the RHC do not require PMP authorization
In the Care Select network, RHC provider specialties are not entitled to receive the monthly administrative fee payment

34. Risk-Based Managed Care
Submit claims to the applicable risk-based managed care (RBMC) managed care entity with the HCPCS/CPT code
Do not include T1015 encounter code
Myers and Stauffer reconciles managed care claims to the provider-specific PPS rate and makes annual settlements
Providers may submit requests for supplemental payments to Myers and Stauffer
Contact information for the MCE’s can be found on the Quick Reference Guide at

35. Helpful Tools

36. Helpful Tools Avenues of resolution
IHCP website at indianamedicaid.com
IHCP Provider Manual
Customer Assistance
Locate area consultant map on:
indianamedicaid.com (provider home page> Contact Us> Provider Relations Field Consultants) or
Web interChange > Help > Contact Us
Written Correspondence
HP Provider Written Correspondence P. O. Box Indianapolis, IN

37. Q&A