1. HP Provider Relations October 2010 Medical Equipment Guidelines

2. Medical Equipment GuidelinesOctober 20102 Agenda –Indiana Medicaid Web site –Updates –Date of Service –Provider Code Sets –Capped Rental –Repair and Replacement –Rolling 12-Month Period –Mail Order Incontinence, Ostomy, and Colostomy Supplies –Billing the Member –Spend-down –Claim Attachments –Prior Authorization –Denials and Resolutions –Helpful Tools –Questions

3. Medical Equipment GuidelinesOctober 20103 Objectives Following this session, providers will: –Be familiar with the Indiana Medicaid Web site –Understand medical equipment guidelines –Understand guidelines for billing the member –Be familiar with spend-down –Understand the claim attachment process –Be familiar with prior authorization inquiry and Prior Authorization Form –Understand the top denials and resolutions

4. Introduce Indiana Medicaid Web site

5. Medical Equipment GuidelinesOctober 20105 Indiana Medicaid Member Web Site http://member.indianamedicaid.com/

6. Medical Equipment GuidelinesOctober 20106 Indiana Medicaid Member Web Site Member tab

7. Medical Equipment GuidelinesOctober 20107 Indiana Medicaid –Qualification Guidelines –Medicaid Programs –Apply for Medicaid Benefits –Check Application Status –Search for a Provider –Choose a Health Plan –Presumptive Eligibility –Pharmacy Information Member tab

8. Medical Equipment GuidelinesOctober 20108 Indiana Medicaid Provider Web Site http://provider.indianamedicaid.com/

9. Medical Equipment GuidelinesOctober 20109 Indiana Medicaid Provider Web Site Provider tab

10. Medical Equipment GuidelinesOctober 201010 Indiana Medicaid Provider Web Site Provider tab

11. Medical Equipment GuidelinesOctober 201011 Provider Tab –Link to the Web interChange –Provider Enrollment –Banners – Bulletins – Newsletters –Workshop Information –Provider Education and Assistance –News and Announcements

12. Describe Medical equipment services

13. Medical Equipment GuidelinesOctober 201013 Updates Procedure Code A4253 - Blood glucose test or reagent strips for home glucose monitor, per 50 strips –Effective for claims with dates of service on or after January 1, 2010: Providers are permitted to bill up to four units, or 200 strips, per beneficiary per 30 days Additional units of A4253 deny unless prior authorization (PA) is obtained Procedure Code A4259 – Lancets, per box of 100 –Effective for claims with dates of service on or after January 1, 2010: Providers are permitted to bill two units, or 200 lancets, per beneficiary per 30 days Additional units of A4259 deny unless PA is obtained CPT copyright 2009 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

14. Medical Equipment GuidelinesOctober 201014 Updates Procedure Code K0739 – Repair or nonroutine service for durable medical equipment other than oxygen equipment requiring the skill of a technician, labor component, per 15 minutes –Effective January 1, 2010, K0739 is a covered code –Replacement for code E1340 –Claims denied with edit 4021 – Procedure Code vs. Program Indicator should be re-filed Procedure Code E2609 – custom wheelchair cushion, any size –Effective May 14, 2010, E2609 is no longer included in the long-term care durable medical equipment (DME) per diem procedure list –Requires prior authorization –May be billed separately to Medicaid

15. Medical Equipment GuidelinesOctober 201015 Updates –Manually Priced Supplies – Effective September 24, 2010, Healthcare Common Procedure Coding System (HCPCS) codes for DME, supplies, and hearing aids that are currently manually priced will require a cost invoice with the claim in conjunction with the retail invoice for claim adjudication A cost invoice is an itemized bill issued directly from the seller of the supply to the provider listing the goods supplied and stating the sum of money due to the supplier Claims will continue to be reimbursed using the retail invoice, unless no invoice is submitted by the provider. The cost invoice will aid OMPP to establish rates for HCPCS –Invoices custom-generated by the provider that include the price of the goods plus the provider’s margin will no longer be accepted for HCPCS codes identified in Bulletin 201037 –Claims with a “from” date of service on or after September 24, 2010, submitted with HCPCS procedure codes listed in the table in BT201037, along with only a retail invoice, or a provider custom- generated invoice, will be denied with: Explanation of Benefit Code 9024 – Inappropriate invoice attached to the claim, please resubmit with the proper attachment

16. Medical Equipment GuidelinesOctober 201016 Date of Service –The date of service is the date the equipment is delivered, not ordered –For the Indiana Health Coverage Programs (IHCP) to reimburse for medical equipment, the member must be eligible on the date of service (date of delivery)

17. Medical Equipment GuidelinesOctober 201017 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

18. Medical Equipment GuidelinesOctober 201018 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 handwritten in the unassigned space to the right

19. Medical Equipment GuidelinesOctober 201019 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 –The provider must service the item at no cost to the IHCP during the rental period Once the equipment is considered purchased, any nonwarranty repairs are billable –A complete list of procedure codes for capped rental can be found in the Indiana Health Coverage Programs Provider Manual, Chapter 8, Section 4

20. Medical Equipment GuidelinesOctober 201020 Capped Rental 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/home medical equipment (HME) is considered purchased and becomes the property of the Office of Medicaid Policy and Planning (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

21. Medical Equipment GuidelinesOctober 201021 Capped Rental –Medicare 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

22. Medical Equipment GuidelinesOctober 201022 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

23. Medical Equipment GuidelinesOctober 201023 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 change in equipment; such requests require PA –A long-term care (LTC) facility’s per diem rate includes repair costs for equipment

24. Medical Equipment GuidelinesOctober 201024 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

25. Medical Equipment GuidelinesOctober 201025 Mail Order Incontinence, Ostomy, and Colostomy Supplies –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 1-888-217-9610 www.binsons.com www.binsons.com Healthcare Products Delivery, Inc (HPD) 1-800-291-8011 www.hpdinc.net www.hpdinc.net J & B Medical 1-866-674-5850 www.jandbmedical.com www.jandbmedical.com Contracted vendors

26. Medical Equipment GuidelinesOctober 201026 Mail Order Incontinence, Ostomy, and Colostomy Supplies –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 the IHCP Provider manual, Chapter 6, Section 5. –The annual maximum allowable reimbursement is $1,950 per member per rolling calendar period

27. Medical Equipment GuidelinesOctober 201027 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 three 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)

28. Learn Billing the member

29. Medical Equipment GuidelinesOctober 201029 Billing the member The following circumstances are the only situations in which an IHCP provider may bill a member: – The service rendered is noncovered 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

30. Medical Equipment GuidelinesOctober 201030 Billing the Member – 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 the IHCP – The waiver should state: Member’s name Reason for noncoverage Service requested Estimated charge – The waiver must not contain any conditional language; for example, the words “if” or “and”

31. Medical Equipment GuidelinesOctober 201031 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 a spend-down is applied to their claim

32. Medical Equipment GuidelinesOctober 201032 Spend-down –Member is eligible on the first of the month –Providers may not refuse service to a member pending verification of the status of spend-down for the month –A provider may bill a member for the dollar amount identified beside ARC 178 on the Remittance Advice (RA) statement –The member is not obligated to pay the provider until the member receives the Medicaid Spend-down Summary Notice listing the amount applied to spend-down Notices are sent on the second business day following the end of the month –Members cannot be billed for more than their spend-down amount –Providers must bill their usual and customary charge to the Indiana Health Coverage Programs (IHCP)

33. Medical Equipment GuidelinesOctober 201033 Spend-down –Providers may discharge a member from their care if a member does not adhere to established payment arrangements of outstanding copayments or spend-down –Providers cannot be more restrictive with spend-down members than with other patients –The first claim processed by the IHCP applies to spend-down, regardless of the date of service within the month –The system uses the billed amount to credit spend-down –Third Party Liability (TPL) amounts are deducted from billed amount prior to crediting spend-down

34. Describe Claim attachments

35. Medical Equipment GuidelinesOctober 201035 Claim Attachment Feature

36. Medical Equipment GuidelinesOctober 201036 Claim Attachment Feature –Unique number assigned by provider –Claim- and document-specific –Each ACN may only be used one time –Select the appropriate report type Report Type describes the document being sent –Transmission Code defaults to “BM” – by mail Electronic and e-mailed attachments are not accepted Attachment Control Number (ACN)

37. Medical Equipment GuidelinesOctober 201037 Claim Attachment Feature

38. Medical Equipment GuidelinesOctober 201038 Claim Attachment Cover Sheet –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) –Write “ACN #” and the assigned ACN on each page of documentation corresponding to that number –Mail cover sheet and supporting documentation to the address at the bottom of the cover sheet, HP, P.O. Box 7259, Indianapolis, IN, 46207

39. Medical Equipment GuidelinesOctober 201039 Claim Attachment Cover Sheet

40. Explain Prior Authorization

41. Medical Equipment GuidelinesOctober 201041 Prior Authorization –Verify eligibility to determine where to send the PA request ADVANTAGE Health Solutions – FFS Prior Authorization Department P.O. Box 40789 Indianapolis, IN 46240 1-800-269-5720 Fax: 1-800-689-2759 ADVANTAGE Health Solutions – Care Select Prior Authorization Department P.O. Box 80068 Indianapolis, IN 46280 1-800-784-3981 Fax: 1-800-689-2759 MDwise – Care Select Prior Authorization Department P.O. Box 44214 Indianapolis, IN 46244-0214 1-866-440-2449 Fax: 1-877-822-7186 –Prior authorization for risk-based managed care recipients should be sent to the appropriate entity Prior authorization by telephone, fax, or mail

42. Medical Equipment GuidelinesOctober 201042 Prior Authorization –Allows the requesting provider to inquire about all nonpharmacy prior authorizations via the Web It does not matter if the PA was submitted via paper, telephone, fax, or Web –The requesting provider and the named service provider may view a PA without the PA number –All other providers must have the PA number to view a PA 278 prior authorization inquiry

43. Medical Equipment GuidelinesOctober 201043 Prior Authorization 278 Prior Authorization Inquiry

44. Resolve Denials and resolutions

45. Medical Equipment GuidelinesOctober 201045 Denials and Resolutions Denial – Edit 593 – Medicare Denied Detail –Cause: At least one detail is a Medicare-denied detail At least one detail contains Medicare coordination of benefits (COB) information –Resolution: Submit separate claims for Medicare-denied details and Medicare-covered details Denial – Edit 3001 – Dates of service not on PA master file –Cause: No prior authorization in IndianaAIM –Resolution: Verify the date of service and procedure code billed are correct on the requested PA Obtain amended/corrected PA if necessary

46. Medical Equipment GuidelinesOctober 201046 Denials and Resolutions Denial – Edit 4021 – Procedure Code vs. Program Indicator –Cause: Procedure code billed is restricted to a specific program –Resolution: Verify procedure code is covered for dates of service billed Verify recipient is eligible for program indicated Denial – Edit 4033 – Invalid Procedure Code/Modifier Combination –Cause: Modifier used is not compatible with procedure code billed –Resolution: Verify modifier is valid and appropriate for procedure code

47. Medical Equipment GuidelinesOctober 201047 Denials and Resolutions 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  Field 22 should be blank Medicare Crossover claims:  The total charge, field 28, and the net charge, field 30, should be the same  Complete field 22 with paid amount and coinsurance and deductible Note: These claims may be filed on the Web interChange

48. Medical Equipment GuidelinesOctober 201048 Denials and Resolutions Denial – Edit 2003 – Recipient Ineligible on Dates of Service – Cause: Member is not eligible for IHCP services being billed –Resolution: Verify the claim was sent to the appropriate billing entity  Fee-for-Service and Care Select to HP  RBMC to the appropriate MCO

49. Medical Equipment GuidelinesOctober 201049 Denials and Resolutions Denial: Edit 6000 – Manual Pricing Required – Cause: Manual pricing is 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

50. Medical Equipment GuidelinesOctober 201050 Denials and Resolutions Denial: Edit 6000 – Manual Pricing Required –Resolution: Submit Manual Pricing DME SUPPLY MANUFACTURING INVOICE 1 SUPPLY ROAD 4/27/09 ANYWHERE, INDIANA 800-123-2345 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 1 59.90 59.90 5 sets in a box - ordered 1 box 59.90/5 = 11.98 each Member rid# 123456789999 Abe Lincoln **********COST INVOICE*************

51. Find Help Resources Available

52. Medical Equipment GuidelinesOctober 201052 Helpful Tools Avenues of resolution –IHCP Web site at www.indianamedicaid.comwww.indianamedicaid.com –IHCP Provider Manual (Web, CD-ROM, or paper) –Customer Assistance Local (317) 655-3240 All others 1-800-577-1278 –Written Correspondence HP Provider Written Correspondence P. O. Box 7263 Indianapolis, IN 46207-7263 –Provider field consultant View a current territory map and contact information online at www.indianamedicaid.comwww.indianamedicaid.com

53. Q&A