1. http://dmasva.dmas.virginia.gov/ 1 Department of Medical Assistance Services E1399 – B9998 – S8189 http://dmasva.dmas.virginia.gov 1 Department of Medical Assistance Services Miscellaneous Codes Roll-up Lines

2. http://dmasva.dmas.virginia.gov/ 2 Department of Medical Assistance Services Miscellaneous (misc.)Codes There are two ways you will see a misc. code billed: –Monthly –One time payments Both scenarios will be reviewed in the next few slides. 2 Department of Medical Assistance Services http://dmasva.dmas.virginia.gov

3. http://dmasva.dmas.virginia.gov/ 3 Department of Medical Assistance Services Monthly Billing - Example 1 There are 3 misc. codes in this case: One of the B9998 24” Mic-key extensions – provider’s cost $9.05 Two of the E1399 Q-tips, which have a set fee of $4.17 Wipes, provider’s cost $68.17

4. http://dmasva.dmas.virginia.gov/ 4 Department of Medical Assistance Services Monthly Billing - Roll-up Line When the Service Authorization (SA) is created each line is entered separately. The system will then create a roll-up line for the misc. codes. The system will roll the two E1399s into one roll-up line and the B9998 into a separate roll up line.

5. http://dmasva.dmas.virginia.gov/ 5 Department of Medical Assistance Services Monthly - Roll-up Line Breakdown On the E1399 roll up line – Both E1399 items were combined into one line: –6 units at $4.17 each for the sterile Q-tips –6 units at $88.62 each for wipes The Roll up line will total 12 units with a total of $560.34 The system then prices each unit at $46.70, even though that is not the actual cost of the items. This is because the total of $560.34 is divided by the 12 units.

6. http://dmasva.dmas.virginia.gov/ 6 Department of Medical Assistance Services Additional Scenarios for Example 1 Sample 1 – if the provider billed for 3 units of wipes and 3 units of sterile Q-tips, the provider is owed $278.37. Which means the amount paid for the 6 is $280.20. The provider would need adjust the claim so the total paid is $278.37. Sample 2- if the provider billed for 4 units of Q-tips and two wipes the provider is owed $193.80. The provider would need to adjust the claim or the auditor could retract $44.46 which is the difference between the amount paid and the amount owed based on the type of products billed for those units.

7. http://dmasva.dmas.virginia.gov/ 7 Department of Medical Assistance Services Auditors Perspective The auditors are reviewing: To see if the amount paid to the provider is appropriate, the auditor would need to know how many of the units were from each type of E1399 item (wipes or sterile Q-Tips). The Provider used 6 of the 12 units. None of the claims will match the invoice or the amount approved under the individual line because the provider must bill one unit as $46.70. To determine if the overall amount paid was accurate, the auditor would need to determine, from the provider, how many of the units were wipes and how many were sterile Q-Tips. The auditor needs to look at the entire SA by the total # of units billed and how that breaks out.

8. http://dmasva.dmas.virginia.gov/ 8 Department of Medical Assistance Services One Time Billing - Example 2 In this case there are 3 E1399 lines that will be included in the roll-up line: One E1399 line is for the IV pole $ 124.80 (provider cost $96) One E1399 line is for the Foam padding twin size $1476.80 (provider cost $1136) One E1399 line is for the Sleep safe bed $10314.72 (provider cost $7934.40) The roll up line was for 3 units at $11916.32

9. http://dmasva.dmas.virginia.gov/ 9 Department of Medical Assistance Services Roll-up Line Breakdown This case is different from the first case because all units were billed at one time equaling the total amount approved. It is also for durable medical equipment which is billed once. The first example was for monthly supplies which makes it harder to determine which items were billed especially if they did not bill all units at the same time.

10. http://dmasva.dmas.virginia.gov/ 10 Department of Medical Assistance Services Provider Responsibilities (Invoices) Things to remember about invoices: When a provider submits for SA they have an estimate of their cost based on the base/primary discount they receive from an established vendor/manufacturer. Once they have approval they will submit the order to the manufacturer, who will then send an invoice to the provider for payment. Most manufacturers will offer an additional/secondary discount if the invoice is paid in a certain amount of time, usually 30 days. Continued on next slide

11. http://dmasva.dmas.virginia.gov/ 11 Department of Medical Assistance Services Provider Responsibilities – Cont. If the provider gets an additional discount the provider should do one of the following: 1.Adjust the approved amount of the service authorization through KePRO 2. Only bill the amount based on the true provider cost (after secondary discount)plus 30% 3. If the provider has already billed the original amount and received a secondary discount they can adjust the claim to the correct amount.

12. http://dmasva.dmas.virginia.gov/ 12 Department of Medical Assistance Services Auditors Perspective In this case there is one point that should be considered when looking at the invoice: –At the bottom of the invoice it states, “If paid outside of the terms, you only receive the 1 st 20% discount. –The auditor should confirm with provider to make sure the provider got both discounts. –If the provider received an extra discount then the provider was overpaid and the auditor will retract the overpayment.

13. http://dmasva.dmas.virginia.gov/ 13 Department of Medical Assistance Services Suggestions For monthly supplies items (only) consider submission of separate PAs for each misc. code. Please remember this creates more work for the provider and KePRO. If you have multiple misc. codes please try and create as few service authorizations as possible. It is important for the provider to keep good records. Continue to next slide

14. http://dmasva.dmas.virginia.gov/ 14 Department of Medical Assistance Services Suggestions Cont. For misc. items that are monthly orders it is especially important to keep all records that relate to the same service authorization together so it is easier for the provider and auditor to access the appropriate amount that should be billed. It is the providers responsibility to present an accurate picture of what was provided to the Medicaid individual.

15. http://dmasva.dmas.virginia.gov/ 15 Department of Medical Assistance Services Resources DMAS has a dedicated email address specifically for providers for questions about DME. (dme@dmas.virginia.gov).dme@dmas.virginia.gov This is not a secure email so please do not include individual specific information. Questions should pertain to polices, codes, or rates and should not pertain to preauthorization, billing or claims. Please refer these questions to the appropriate unit. Preauthorization – Kepro - 888.827.2884 or via email at ProviderIssues@kepro.org or PAUR06@dmas.virginia.gov ProviderIssues@kepro.orgPAUR06@dmas.virginia.gov Billing/Claims – Call the helpline at 800-552-8627.