1. October 2009 Waiver Billing Presentation Presented by the EDS Provider Field Consultants

2. Waiver Billing Presentation 2/ October 2009 Session Objectives Definition of Medicaid Waiver Provider Enrollment Member Eligibility Billing Claim Form and NPI Spend-down Adjudicated Claim Information Paper Claim Filing Hints Remittance Advice Claim Voids and Replacements (Adjustments) Most Common Denials Helpful Tools Questions Agenda

3. Waiver Billing Presentation 3/ October 2009 Session Objectives At the end of this session, providers will understand: Definition of a Medicaid waiver Indiana’s two new demonstration grant waivers Waiver provider enrollment process Requirements necessary for a member to qualify for waiver services How spend-down impacts claim processing How to verify member eligibility How to submit and adjust claims

4. Waiver Billing Presentation 4/ October 2009 Definition of Medicaid Waiver In 1981 the federal government created Title XIX Home and Community-Based Services Program This act, referred to as the waiver program, created exceptions to, or “waived” traditional Medicaid requirements A waiver is what the State government requested from the Centers for Medicare & Medicaid Services (CMS) to obtain additional funding through the Medicaid program –It allows for the provision and payment of HCBS services that are not provided through the Medicaid State plan Medicaid waiver programs are funded with both State and federal dollars All Indiana waiver programs have been initiated by the Indiana General Assembly and approved by CMS

5. Waiver Billing Presentation 5/ October 2009 What Is the HCBS Waiver Program? Traditionally, Medicaid paid for institutional-based services only; however, the HCBS waiver programs allowed services to be “waived” from Traditional Medicaid payment methodology The Medicaid HCBS waivers fund supportive services to individuals in their own homes or in community settings, rather than in a long-term care facility setting The Medicaid HCBS waivers fund services to individuals who: – Meet the level of care specific to a waiver – Meet the financial limitations established by the waiver

6. Waiver Billing Presentation 6/ October 2009 What Is the HCBS Waiver Program? In addition to waiver services, waiver members receive all Medicaid services under the State Plan (Traditional Medicaid), for which they are eligible. The State administers seven HCBS waivers and grants under three categories: –Nursing Facility Level of Care Waivers (includes three waivers/grants) –ICF/MR Level of Care Waivers (includes three waivers) –Psychiatric Residential Treatment Facilities Level of Care

7. Waiver Billing Presentation 7/ October 2009 HCBS Waivers Nursing Facility Level of Care Waivers and Grant Administered by the Division of Aging Aged and Disabled Waiver (AD) Traumatic Brain Injury Waiver (TBI) Money Follows the Person Demonstration Grant (MFP) ICF/MR Level of Care Waivers Administered by the Division of Disability and Rehabilitative Services Developmental Disabilities Waiver (DD) Autism Waiver (AU) Support Services Waiver (SS)

8. Waiver Billing Presentation 8/ October 2009 HCBS Waivers Psychiatric Residential Treatment Facilities Level of Care Grant Administered by the Division of Mental Health and Addiction Community Alternatives to Psychiatric Residential Treatment Facilities Demonstration Grant (CA PRTF)

9. Waiver Billing Presentation 9/ October 2009 Community Alternatives to Psychiatric Residential Treatment Facilities (CA PRTF) Demonstration project through CMS Goal is to demonstrate that cost-effective, intensive community-based services can serve as alternative to treatment in a PRTF or assist in a child/youth’s transition back to the community from a PRTF More than 21 million federal dollars for five-year duration 40 Indiana counties serve as access sites for grant services Offer eight services: Wraparound Facilitation, Wraparound Technician, Respite Care, Non-Medical Transportation, Habilitation, Clinical and Consultative Therapeutic Services, Flex Funds, and Training and Support for Unpaid Caregivers More information about services offered and rates: www.in.gov/fssa/dmha/6643.htm

10. Waiver Billing Presentation 10/ October 2009 Money Follows the Person (MFP) Grant Demonstration program through CMS Helps interested individuals transition out of a nursing facility and into a community-based setting ADVANTAGE Health Solutions case managers help facilitate transition Participants may receive waiver services plus additional program services: –Additional transportation After 365 days participants transfer seamlessly to one of the waivers

11. Waiver Billing Presentation 11/ October 2009 IFSSA Waiver Divisions The following divisions support the administration of the HCBS waivers and grants: Developmentally Disabled, Support Services, and Autism Waivers: Division of Disability and Rehabilitative Services 402 W. Washington St., Room W453 Indianapolis, IN 46207 Aged and Disabled and Traumatic Brain Injury Waivers and Money Follows the Person Demonstration Grant: Division of Aging 402 W. Washington St., Room W454 Indianapolis, IN 46207 Community Alternatives to PRTF Demonstration Grant Division of Mental Health and Addiction 402 W. Washington St., Room W353 Indianapolis, IN 46204

12. Waiver Billing Presentation 12/ October 2009 Provider Enrollment Process The prospective waiver provider initiates the waiver enrollment process by contacting one of the two Indiana Family and Social Services Administration (IFSSA) waiver divisions The waiver divisions coordinate a thorough certification process with the prospective provider A waiver provider must be certified by the appropriate waiver division at the IFSSA before EDS can process a Medicaid waiver enrollment application

13. Waiver Billing Presentation 13/ October 2009 New Provider Enrollment Enrollment forms are in electronic format on Web by using www.indianamedicaid.com 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

14. Waiver Billing Presentation 14/ October 2009 New Provider Enrollment

15. Waiver Billing Presentation 15/ October 2009 New Provider Enrollment

16. Waiver Billing Presentation 16/ October 2009 Download the IHCP Waiver Provider Application: –Visit www.indianamedicaid.comwww.indianamedicaid.com –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 IHCP Waiver Provider Application and Maintenance Form Complete the enrollment application (original signatures are required) Avoid having your application returned; call 1-877-707-5750 if you have questions about the enrollment forms Process Provider Enrollment

17. Waiver Billing Presentation 17/ October 2009 The enrollment packet must include: –Completed IHCP Waiver Provider Application and Maintenance Form (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, Waiver P.O. Box 7263 Indianapolis, IN 46207-7263 Mailing the Application Provider Enrollment

18. Waiver Billing Presentation 18/ October 2009 Provider Updates It is the provider’s responsibility to inform the IFSSA waiver divisions and the IHCP when there are changes to their enrollment profile Updates to the following information must be submitted to the IFSSA waiver division instead of EDS’ Provider Enrollment Unit –Waiver Specialty Change- Tax Identification Changes –Name Changes- Changes in Ownership (CHOW) –Service Location Additions Changes to the Home address must be mailed to Provider Enrollment on paper Updates to the following information must be submitted to the EDS Provider Enrollment Unit either on paper or electronically: –Address changes (mail-to, pay-to, and service location) –Telephone number changes –Banking information changes (if enrolled in electronic funds transfer) Requests for changes on paper must be submitted using the IHCP Billing Provider Application available at www.indianamedicaid.com

19. Waiver Billing Presentation 19/ October 2009 The Division of Family Resources (DFR): Enters member application into their eligibility tracking system known as the Indiana Client Eligibility System (ICES) Determines member eligibility status Makes spend-down determinations Maintains member information and eligibility files Where it Begins Member Eligibility

20. Waiver Billing Presentation 20/ October 2009 Waiver Program Member Eligibility Members Must Qualify for Waiver Program Eligibility Individuals who meet waiver Level of Care status and who are Medicaid eligible may be approved to receive waiver services A limited number of slots are available for each waiver and the waiver slot number is approved by the CMS A Medicaid-eligible individual cannot receive waiver services until: –A slot is available –A waiver Level of Care is established for the member –A cost-comparison budget is approved (demonstrates cost-effectiveness of waiver services)

21. Waiver Billing Presentation 21/ October 2009 Waiver Program Member Eligibility Once Eligibility Requirements Are Met A case manager, along with the client and/or client’s representative, as well as other service providers, develop a Plan of Care (POC), which is reviewed by the State The Notice of Action (NOA) lists the approved services for which the client may receive, along with the approved date span, units, and charge per unit Information from the NOA is sent to EDS for placement on the member’s Prior Authorization record for appropriate claims payment Claims pay only if PA dollars, units, and services are available for the dates of service submitted on the claim

22. Waiver Billing Presentation 22/ October 2009 Receives member data from ICES Updates IndianaAIM within 72 hours Provides and supports the eligibility verification systems (EVS) Makes EVS available 24 hours a day, seven days a week EDS Role Member Eligibility

23. Waiver Billing Presentation 23/ October 2009 Three EVS are available: Automated Voice Response (AVR) –1-800-738-6770, or –(317) 692-0819, Indianapolis area Omni swipe card terminal device Web interChange How to Verify Member Eligibility

24. Waiver Billing Presentation 24/ October 2009 AVR provides the following: Member eligibility verification Benefit limits Prior authorization Claim status Check write Contact AVR at (317) 692-0819 in the Indianapolis local area or 1-800-738-6770 EVS Using the Telephone Automated Voice Response

25. Waiver Billing Presentation 25/ October 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

26. Waiver Billing Presentation 26/ October 2009 The following is available through Web interChange: Member information available by Member ID, SSN, Medicare Number, or Name and DOB Spend-down information DFR information Detailed TPL information Online TPL update requests Web interChange is accessible via www.indianamedicaid.com www.indianamedicaid.com EVS Using the Internet Web interChange

27. Waiver Billing Presentation 27/ October 2009 Waiver Billing Notice of Action –Lists the approved service provider –Lists the approved service codes –Gives the approved units and dollar amounts CMS-1500 claim form –Use service code approved on the NOA –Include all modifiers listed with the service code – U7 will identify this is a waiver service Refer to the HCBS Waiver Program Provider Manual for information regarding –Service Definitions –Allowable Services –Service Standards –Documentation Standards

28. Waiver Billing Presentation 28/ October 2009 Authorized Services You may only bill for authorized services. For services to be authorized they must: Meet the needs of the member Be addressed in the member’s Plan of Care (POC) and/or Individualized Support Plan (ISP) Be provided in accordance with the definition and parameters of the service, as established by the waiver

29. Waiver Billing Presentation 29/ October 2009 Claim Form and NPI Waiver providers use the CMS-1500 claim form when submitting paper claims for services Waiver providers are considered A-typical and are not required to report an NPI on their claim Waiver providers may submit claims using their Legacy Provider Identifier (LPI) as they have in the past Waiver providers do not report or use a taxonomy code Note: Targeted case managers who provide traditional Medicaid services for determining the waiver Level of Care should report and use their NPI

30. Waiver Billing Presentation 30/ October 2009 Spend-down Spend-down is assigned by the Division of Family Resources at the time of the eligibility determination Only the member and DFR are aware of the spend-down amount EDS credits the member’s spend-down based on the usual and customary charge billed on the claim Spend-down is credited on claims based on the order they are processed ARC 178 appears on the Remittance Advice when spend-down is credited on claims Providers may bill the member for the amount listed beside ARC 178 Member is responsible to pay upon receipt of the Spend-down Summary Notice

31. Waiver Billing Presentation 31/ October 2009 Adjudicated Claim Information The internal control number (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 2009158150000 Internal Control Number

32. Waiver Billing Presentation 32/ October 2009 Paper Claim Filing 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 Send claims to EDS Waiver Program Claims P.O. Box 7269 Indianapolis, IN 46207-7269 Review the Remittance Advice (RA) closely Helpful Hints

33. Waiver Billing Presentation 33/ October 2009 Remittance Advice 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 Paper RAs no longer mailed to providers –RAs available on Web interChange –Check/RA Inquiry function –Effective September 1, 2009 Statement with Claims Processing Information

34. Waiver Billing Presentation 34/ October 2009 Claim Adjustments “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, suspended, 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 from the date of service “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

35. Waiver Billing Presentation 35/ October 2009 Most Common Denials Cause –The claim is an exact duplicate of a previously paid claim Resolution –No action required, as the claim has already been paid Edit 5001 – Exact Duplicate

36. Waiver Billing Presentation 36/ October 2009 Cause –Waiver provider has billed for a recipient who does not have a waiver Level of Care for the date of service Resolution –Contact the waiver case manager to verify the LOC information is accurate –Verify the correct date of service has been billed Edit 2013 – Recipient Ineligible for Level of Care Most Common Denials

37. Waiver Billing Presentation 37/ October 2009 Cause –Provider has billed a procedure code that is invalid for the Waiver program Resolution –Verify the correct procedure code has been billed –Verify the procedure code billed is present on the Notice of Action Edit 4216 – Procedure Code not eligible for Recipient Waiver Program Most Common Denials

38. Waiver Billing Presentation 38/ October 2009 Cause –The date of service billed is not on the prior authorization file Resolution –Verify the correct date of service has been billed –Verify the date of service billed is on the Notice of Action Edit 3001 – Date of Service Not on PA Database Most Common Denials

39. Waiver Billing Presentation 39/ October 2009 Helpful Tools IHCP Web site at www.indianamedicaid.comwww.indianamedicaid.com IHCP Provider Manual (Web, CD-ROM, or paper) HCBS Waiver Provider Manual Customer Assistance –1-800-577-1278, or –(317) 655-3240 in the Indianapolis local area Written Correspondence –P.O. Box 7263 Indianapolis, IN 46207-7263 Provider Relations field consultant –View a current territory map and contact information online at www.indianamedicaid.com www.indianamedicaid.com Avenues of Resolution

40. Waiver Billing Presentation 40/ October 2009 Division of Disability and Rehabilitative Services 402 W. Washington St., Room W453 Indianapolis, IN 46207 Division of Aging 402 W. Washington St., Room W454 Indianapolis, IN 46207 Division of Mental Health and Addiction 402 W. Washington St., Room W353 Indianapolis, IN 46204 Helpful Tools Avenues of Resolution

41. Waiver Billing Presentation 41/ October 2009 Questions

42. 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. © 2009 Hewlett-Packard Development Company, LP. Office of Medicaid Policy and Planning (OMPP) 402 W. Washington St, Room W374 Indianapolis, IN 46204 EDS, an HP Company 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204