PROVIDER UPDATE
VOLUME 9, NUMBER 2
APRIL 1992
ALL PROVIDERS
RECIPIENT ELIGIBILITY CARD
Medicaid of Louisiana is now printing a different message on Louisiana
recipient Medical Eligibility cards for recipients who are eligible for KIDMED/EPSDT
services. Providers should review
the example provided in the Attachments
section of this issue of the Provider
Update.
NEW HCFA-1500 FORMS: ORDERING
INFORMATION
The revised HCFA-1500 claim form may be ordered from the Superintendent of
Documents and negatives for the HCFA-1500 may be obtained from the Government
Printing Office (GPO). Providers
should note that copy machine copies of the HCFA-1500 are not acceptable.
The Superintendent of Documents will sell copies of the 1500 as indicated
below.
NOTE:
All the forms listed below are sensor coded.
Type of Form
Quantity Per Package
Stock Number
Single Sheet
100
017-060-00468-1
2-Part Snapout
100
017-060-00469-0
1-Part Continuous
2500
017-060-00470-3
2-Part Continuous
1400
017-060-00471-1
NOTE:
On any order of 100 packages or more to be shipped to one address, a 25%
discount may be applied. For orders
of 100,000 copies or more, the Superintendent of Documents can furnish the 1500
preprinted with the practitioner's name, address, and ID number, or he can
customize the form in certain other ways. For
further information when ordering 100,000 copies, providers should call Mr.
Howard Johnson at (202) 521-2404.
Checks, money orders, or mail orders should be mailed to the following
address:
U.S. Government Printing Office
Superintendent of Documents
Washington, DC 20402
Providers charging orders to Mastercard, Visa, Choice, or SupDocs Deposit
Accounts should call (202) 783-3238 (SupDocs
Order Desk) between 8:00 A.M. and 4:30 P.M. Eastern time.
NOTE:
Orders must be placed with the SupDocs stock number.
The GPO will sell negatives and a
specifications package which may be used for printing the 1500.
With these negatives, the printer may produce copies of the 1500. This
negative may be reused indefinitely. The
negatives may be altered to overprint a name, address, and ID number.
The negatives may be purchased by check or money order payable to
"The Public Printer." Providers
should forward orders for the negatives to the Asst.
Supt. Of Dept. Acct. Rep. Div., U.S. Govt. Printing Office, Room C-830,
Washington, DC 20401. Providers
should not submit a purchase order, voucher, or similar form for purchase
because this office can process payments by check or money order only.
The GPO will ship orders
approximately 5 working days after receipt of the order. If additional information is needed in ordering negatives,
providers should contact Robin Wilkins at (202)
512-1257.
Providers who have questions
about any of the ordering information provided in this article may call (504)
927-3390.
CLAIMS RESOLUTION PROCEDURES
It has come to our attention that there is a misunderstanding among providers
regarding the correct procedure for claims resolution.
If a claim is over one year old, then it must be submitted to Unisys
Provider Relations with a request for an override of the timely filing
limitations and documentation which reflects that the claim was originally
timely filed. Documentation of
timely filing may be a remittance advice or correspondence from either Unisys or
the Bureau of Health Services Financing which identifies the claim and reflects
that it was filed within one year of the date of service.
If a claim is over two years old, then it must be submitted to the Hospital
Program with a request for an override of the timely filing limitation,
documentation of timely filing, and documentation of the provider's attempt to
resolve the billing problem. If the
provider does not have documentation of timely filing because the patient became
eligible for Medicaid retroactively, then the claim must be submitted to the
MMIS Section with documentation of retroactive eligibility.
Documentation of retroactive eligibility may be either a copy of the
patient's Medicaid eligibility card or correspondence from the local Office of
Family Support which identifies the period of retroactive eligibility.
Claims requiring resolution should be sent to one of the following addresses:
One Year Old:
Paramax Systems Corporation
P. O. Box 91024
Baton Rouge, LA 70821
Attention: Provider Relations
Two Years Old:
B.H.S.F.
P. O. Box 91030
Baton Rouge, LA 70821
Attention: Sandra Victor, Hospital
Program
Retroactive Eligibility
If a claim is over one year old or if a claim is over two years old and the
provider has documentation that the date of service falls within a recipient's
retroactive period of Medicaid eligibility, the claim should be sent with
documentation attached to the following address:
B.H.S.F.
P. O. Box 91030
Baton Rouge, LA 70821
Attention: Cathy Troy, MMIS/Claims
Resolution Unit
NOTE:
Claims involving retroactive eligibility must be submitted to MMIS within
one year of the patient becoming Medicaid eligible.
CHANGE IN BILLING INSTRUCTIONS FOR CODES 77420-52, 77425-52, AND
77430-52
Physicians and billing clerks should read the article entitled "Billing
Instructions for CPT-4 Codes 77420, 77425, and 77430," which is printed on
page 13 of the October 1991 issue of the Provider
Update for we are, with this notification, changing the billing instructions
for codes 77420-52, 77425-52, and 77430-52, effective with claims processed
after May 1, 1992, to allow these codes to be billed electronically.
These changes in billing instructions should also alleviate the problem
providers and our Medical Review Unit are having with the new HCFA-1500 form its
lack of a description column.
Effective with claims received after May 1, 1992, providers should begin
billing in the following manner for complete courses of therapy consisting of
numbers of fractions not evenly divisible by 5:
Providers should place either code 77420-52, 77425-52, or 77430-52 (CPT/HCPCS-Modifier)
in Item 24D of the claim form and the number of fragments being billed, either
1, 2, 3, or 4, in Item 24G (Days or Units column).
Then, the computer will pay either one-fifth, two-fifths, three-fifths, or
four-fifths of the fee on file for the code billed.
For example, to bill for a complete course of therapy in which 23 fragments
were given, code 77420 (assuming the simple level of treatment was given) should
be placed in Item 24D, and 4 should be placed in Item 24G.
Then, code 77420-52 and 3 should be placed in Items 24D and 24G,
respectively, on the next line of the claim form.
To bill for a complete course in which 7 fragments were given, code 77430
(assuming complex treatment was rendered) should be placed in Item 24D, and 1
should be placed in Item 24G. On
the next claim line, code 77430-52 and 2 should be placed in Items 24D and 24G,
respectively.
NOTE:
The numbers 1 through 4 are the only numbers that should be used in the
units column if the code being billed is modified.
Also, span dates should continue to be
used.
If questions arise concerning these instructions, providers should call
Kandis V. McDaniel, Physicians Program Manager, at (504)
342-9490.
INCREASE IN FEES FOR CRITICAL CARE CODES 99291 & 99292
Medicaid of Louisiana is pleased to announce an increase in fees for critical
care services (CPT-92 codes 99291 and 99292), effective with date of service
January 1, 1992. The fee for code
99291 was increased to $207.00, and the fee for code 99292 was increased to
$128.00.
NOTE:
Adjustments may be requested.
NEONATAL CRITICAL CARE
In billing for neonatal critical care services, the coding section of the
American Medical Association has advised that neonatologists may bill code 99291
(Critical care; first hour), even though they may not spend a full 60 minutes
with each neonate they see on a given day.
In other words, if a neonatologist spends only ten minutes on a given day
with Baby A, he may still bill code 99291 on that day for that child.
However, the 10, 35, or 50 minutes spent must be spent with
the child before 99291 may be billed. Code
99291 may not be billed if all the critical care provider does is spend time in
the unit directing the auxiliary personnel.
Only time actually spent with the patient may be counted.
Additionally, the doctor may not bill for an additional thirty minutes of
care (code 99292) until he has spent a full 60 minutes with the child.
Therefore, records must be documented.
Again, just being in the unit and directing others does not count.
The time billed must have been spent with the baby.
If the professional bills code 99292 after having spent only 50 minutes
with Baby A and 15 minutes directing personnel, he will have billed code 99292
in error.
UNITS FOR 95920
The number of units that may be billed per day for procedure code 95920 (Intraoperative
neurophysiology testing, per hour) has been increased from one to four.
Hours of testing over four will pend to the Medical Review Unit for
review. The fee for each hour of
testing is $50.00.
FUNDING FOR 99238
CPT-92 procedure code 99238 (Hospital discharge day management) has been
funded at $32.00, effective with date of service January 1, 1992.
Now, providers should bill code 99238, rather than code 90260 (Subsequent
hospital care, each day; intermediate service), for the last day of inpatient
care.
INCREASE IN FEES FOR 93307 AND 93308
The fees for Echocardiography (procedure codes 93307 and 93308) have been
increased to $208.00 and $113.00, respectively, effective with date of service
November 1, 1991. Adjustments may
be requested.
CRITICAL CARE POLICY CHANGE
Medicaid of Louisiana is pleased to announce that, effective with date of
service January 1, 1992, claims for concurrent critical care services (procedure
codes 99291and 99292) for recipients to the age of 21 will be honored.
Prior to January 1, 1992, error edit 730 (One inpatient hospital
initial/subsequent care visit allowed per day) prevented the payment of second,
third, and fourth claims for visit services to Client A.
As a result, the provider whose claims was processed first was the only
one to receive payment.
This edit has been lifted for critical care services only
for only clients to the age of 21 effective with the date of service
stated above.
Providers who may have had claims for critical care services denied since
January 1, 1992, may rebill.
HCFA-1500 DIFFICULTIES
Our medical review unit has begun reviewing claims submitted on the new
HCFA-1500 claim form and are having difficulty with those claims where the
procedure code pends for review and where the medical review resolution
procedures require a description. There
is no place on the form for a description; and, therefore, we are having to deny
some of the claims and request a report.
However, if providers billing codes 90742, 95150, 95155, and 99070 would
attach a report to their claims before submitting them for processing, we would
be able to reduce the number of claims being denied.
If claims with these codes are submitted without a report, the claims
will be denied with the error codes listed below:
732 Attach detailed description of procedure
925 Send office records for date of service
950 Attach both operative and history report
PHYSICIANS & CERTIFIED NURSE MIDWIVES
INSERTION AND REMOVAL OF NORPLANT
Certified nurse midwives may bill and be reimbursed for the insertion and
removal of the Norplant contraceptive implant effective with date of service May
1, 1991.
At the current time, the codes for Norplant insertion and removal are 58302
and 58303. However, effective with
date of service April 1, 1992, these codes will be replaced by codes 11975
(Insertion or reinsertion, implantable contraceptive capsules) and by 11976
(Removal without reinsertion, implantable contraceptive capsules).
Fees will remain the same.
Providers who check their Norplant patients a week after implantation may
bill for no higher level of visit than a problem-focused exam with
straightforward medical decision making (code 99201, $22.00) if the patient is
new or for no higher than a minimum visit (code 99211, $14.00) if the patient is
established.
RADIATION TREATMENT DELIVERY CENTERS
FUNDING OF TECHNICAL COMPONENT CODES
The technical component codes for radiation treatment delivery (procedure
codes 77401 and 77416) have been placed on the procedure/formulary file
effective with date of service January 1, 1992.
These codes replace the "Y" alpha-numeric codes which were
placed in non-pay status effective the
same date. The fees for codes 77401 through 77416 are as follows:
CODE
FEE ($)
77401
22.00
77402
53.00
77403
26.00
77404
64.00
77406
80.00
77407
56.00
77408
76.00
77409
79.00
77411
90.00
77412
56.00
77413
76.00
77414
89.00
77416
90.00
TRANSPORTATION PROVIDERS
THE MT-3 FORM
Non-emergency medical transportation providers are expected to provide MT-3
forms (Verification of Medical Transportation) to the recipient, who is, in
turn, expected to certify that the authorized transportation was received by
signing the form.
Then, the MT-3 form is returned to the driver after a signature is obtained
from the medical provider's office, indicating that the recipient received the
service.
Providers/drivers are not permitted to obtain recipient or medical signatures
until after the services have been provided.
If transportation providers find that driver's have presigned MT-3 forms
in inventory, all such forms should be destroyed immediately.
Failure to comply with this policy will result in future recoupments.
THE MT-4 FORM
Effective July 1, 1991, all claims submitted without the current MT-4 (Daily
Trip Log) will be subject to recoupment payments.
A sample form and the appropriate instructions are provided in the
attachments section of this issue of the Provider Update. Providers
should use the attached form for copying their inventory.
PHARMACISTS AND PRESCRIBERS
NICOTINE ADH.PATCHES
Nicotine adhesive patches are covered only with a handwritten prescription
signed by the prescribing practitioner, i.e., an original script only, with no
provisions for refills; i.e., the physician will need to rewrite a prescription
each time.
Also, physicians must certify, in their own handwriting, either directly on
the prescription or on an attachment to the prescription that recipients are
enrolled in a physician-supervised behavioral program in order for Medicaid to
provide coverage for nicotine adhesive patches.
ERROR 462 DENIALS
We have been notified by drug manufacturers through the submission of drug
utilization rebate data that pharmacists are billing and getting reimbursed for
NDC numbers which are obsolete/discontinued or which have expired shelf-life
dates.
Thus, we ask that providers use the NDC for the drug product from the package
from which the drug is being dispensed. Otherwise,
the claim will be denied for the improper NDC with error message 462
(Manufacturer notified us that NDC is obsolete.)
DRUG LIMITS SUSPENDED
Effective for services beginning January 28, 1992, the Federal Upper Limits
on the following drugs have been suspended:
Generic Name:
Tetracycline Hydochloride
125mg/5ml syrup 480ml
Gentamicin
Sulfate Opth. Oint.
3mg/gm
Primidon,
250mg tablet
Trigexyphenidyl HCI
2mg tablet
5mg tablet
Adjustments should be submitted.
Effective December 9, 1991, the limits for the following drug were suspended:
Generic Name:
Verapamil Hydrochloride 40mg tablets.
MAC OVERRIDES
Bureau reports and audit findings continue to disclose that providers who
tape bill have high percentages of Maximum Allowable Costs (MAC) override
claims. When these providers are
audited, findings for these providers do not reveal that the wording "brand
necessary" or "brand medically necessary" was on the
prescription.
Additional research reveals that this problem is occurring even when single
source drugs or multi-source drugs which do not have a MAC are billed.
In addition, we have identified some tape billing systems which have software
packages that do not contain appropriate fields to reflect authorized MAC
overrides. For example, one
software package has a field which indicates whether generic substitution is
allowed. The default can be
programmed to indicate yes or no.
If yes is entered, then generic
substitution is allowed, and no MAC override occurs.
If no is entered, then generic
substitution is not allowed, and a MAC override occurs.
Another software package may indicate whether the pharmacist may
"Dispense as written." This
field is used to reflect that a drug was dispensed as the physician prescribed,
and it allows a MAC override whether or not a valid MAC override was authorized
when yes was entered for that field.
Thus, providers should verify that their internal procedures for indicating
MAC overrides are accurate and are not resulting in claim denials.
We have made a revision to the pharmacy program claims processing system
to assist pharmacists in identifying if they are providers with this problem.
This addition is edit 463 which occurs when providers bill for a drug
with a MAC override indicator and the drug is not a MAC drug.
The error message on the drug claim rejection notice produced when this
error occurs will be "Drug does not need MAC override."
In order to correct drug claim rejection notices, providers must remove the
MAC override indicator and resubmit the notice to Paramax for processing.
If the provider is a tape biller, we recommend that the claim be rebilled
without the MAC override.
In the near future, we will also be providing an additional field on the
remittance advice to reflect those claims which have been processed and had a
MAC override on the claim. This
will be noted on the line item for a claim with a "C."
If a "C" is not printed on the remittance advice line item for
the claim, then the claim was processed without a MAC override.
Providers should note that state and federal regulations require that the MAC
limits for drugs do not apply if, "a physician certifies, in his own
handwriting, in his medical judgement, that a specific brand is medically
necessary for a particular recipient."
The wording of the certification should testify to the medical necessity
of the brand name drug by stating either "brand medically necessary"
or "brand necessary." The
phrases "do not substitute," "no generics please," or
"dispense as written" are not acceptable for overriding MAC
limitations.
IMMUNOSUPPRESSANT DRUGS
There are some providers who continue to have difficulty getting claims for
immunosuppressant drugs processed. Therefore, we are taking this opportunity to describe the
coverage of these drugs.
Effective January 1, 1987, Medicare Part B began paying for FDA-approved
immunosuppressant drugs. This
benefit is subject to the Part B deductible and coinsurance provisions, and it
is limited to a one-year period after the date of the Medicare-covered
transplant.
The drugs presently covered under the immunosuppressive drug program are
listed as follows:
J7500
Imuran (Azathioprine), oral tablets, 50mg
J7501
Imuran parenteral, vial 100mg/ml
J7502
Sandimmune (Cyclosporin) oral solution, 100mg/ml
J7503
Sandimmune parenteral, 250mg
J7504
Lympocyte Immune Globulin Orthoclone, per ml
J7505
Orthoclone, per ml
W9075
Prednisone oral tablets, 5mg
W9076
Prednisone oral tablets, 10mg
W9077
Sandimmune (Cyclosporin), 25mg capsules
W9078
Sandimmune, 100mg capsules
Claims should first be sent to Transamerica Occidental Life.
Their address is as follows:
Transamerica Occidental Insurance
Medicare Immuno Drug Claims
P.O. Box 50065
Upland, CA 90785-5065
After Transamerica Occidental Life has processed the claim, then the claim,
as well as the Explanation of Benefits, should be forwarded to Paramax for
payment of coinsurance and deductible amounts, where applicable.
HCFA-1500 claim form instructions are included in the Pharmacy
Provider Manual on pages 4-3a and 4-3b.
If the transplant date is more than one year old, then the pharmacy claims,
as well as the documentation of the transplant date from either the physician or
hospital, should be forwarded to the Paramax Provider Relations Unit (TPL) for
processing and override of the Medicare eligible edit.
For non-transplant payments with Medicare Part B, the following policy
applies:
"When a prescription is filled for these drugs and the individual is
not an organ transplant patient and Is covered by Medicare Part B, providers
should attach a copy of a physician statement verifying the diagnosis of each
claim submittal."
If the recipient does not have Medicare Part B coverage, providers should
bill as they normally would.
USING CORRECT NDCS WHEN BILLING
In accordance with the drug rebate agreements, manufacturers have challenged
the drug utilization billed to Medicaid of Louisiana.
Their reasons for disputing our utilization data include the opinion that
NDCs are obsolete, discontinued, or that the shelf lives of particular NDCs have
expired. Manufacturers have also
disputed the Louisiana Medicaid drug utilization data because they believe that
it exceeds their threshold level for this state.
Thus, we will be researching this information and comparing it to our
Medicaid utilization data to verify the manufacturer's reasons for disputing
Louisiana data. Based on this
review, we will be confirming pharmacists' utilization and purchases for
specific NDCs.
Audits and reviews have also identified that pharmacists are billing NDCs
specifically for generic products which have not been purchased by their
pharmacy. Audit findings include
computerized pharmacies which maintain pull-down menus for NDC billing purposes
but do not include the NDC for the generic product which has been purchased and
dispensed by the provider.
However, these billing practices are not in accordance with federal and state
regulations, requiring that the pharmacist bill the NDC from the actual package
from which the pharmacist is dispensing.
We recommend that providers review software programs that are used to
identify and correct this problem because failure to comply with program
requirements could result in administrative sanctions, including possible
termination from the program.
Finally, it is imperative that accurate records be maintained by Medicaid
participating pharmacies and that NDC codes submitted for payment be taken from
the package from which the drug is dispensed.
PHARMACISTS, PRESCRIBERS AND DME PROVIDERS
DIABETIC SUPPLIES
Prior to April 1, 1992, diabetic supplies required prior approval through the
review of medical necessity.
Effective for prescription services beginning April 1, 1992, diabetic
supplies for Medicaid EPSDT individuals under the age of 21 with
insulin-dependent diabetes mellitus will be transferred from the prior approval
program into the pharmacy program. Aid
category 15 (Foster Care Children), however, are not covered.
Aid category 15 is indicated on the Medicaid eligibility card with a 1
and a 5 in the third and fourth digit, respectively, of the eligibility number.
The covered supplies include disposable insulin syringes, blood glucose
monitoring strips, urine ketone monitoring strips, and lancets, and they require
a prescription. For disposable
syringes, the prescription must contain the prescribing physician's written
statement that the recipient is insulin-dependent.
Disposable insulin syringes, blood glucose monitoring strips, and lancets are
to be dispensed in the amount of 100 or a month's supply, whichever is greater.
Providers are to bill their usual and customary charges for these supplies.
The maximum payment for these supplies will be the prevailing wholesale
cost plus 50%.
Providers should note, however, that blood glucose monitors must still be
prior approved through the DME program. The Prior Authorization Unit will approve a home blood
glucose monitor if the following conditions are met:
1. The recipient is a Type I insulin-dependent diabetic and under the age of
21;
2. The physician has stated that the recipient or a responsible family
member or care taker can be trained to use the particular device in an
appropriate manner to monitor the patient and can assure that the intended
effect is achieved; and
3. The device is designed for home use rather than for clinical use.
DME PROVIDERS
DME AND MD PRESCRIPTION REQUIREMENTS
Our regulations require that all durable medical equipment and supplies be
recommended by an MD for consideration of Medicaid authorization to purchase or
rent.
The Prior Authorization Unit at Paramax will accept and process requests for
DME supplies submitted on a PA01 request form or doctor's order forms when
provider-designed equipment list forms are attached and signed by the
prescribing physician in lieu of a signed prescription.
Providers who do not have predesigned equipment list forms should continue to
attach the physician's prescription or his letterhead copy to the PA01.
WHEELCHAIRS
DME providers may now submit requests for special or customized type
wheelchairs for residents of nursing homes and mental retardation facilities,
who are both Medicaid and Medicare Part B eligible, to the Unisys/Paramax Prior
Authorization Unit for review since Medicare does not cover wheelchairs for LTC
residents. It is not necessary to
bill Medicare first.
In addition, the Prior Authorization Unit may now review requests for special
or customized wheelchairs for residents of nursing homes (ICF I, II, and SNF),
who receive only Medicaid benefits because nursing homes are no longer required
to furnish all wheelchairs for their residents.
Under the revised LTC standards for payment for ICF I, II, and SNF
nursing homes, these facilities are only required to furnish standard type
wheelchairs.
HOSPITALS, PHYSICIANS AND DME PROVIDERS
REQUESTING APPROVAL
Provided below are the procedures providers must follow to request the
approval of any outpatient surgery done on an inpatient basis and to request an
extension of hospital days. All of
these requests must be submitted on a PA01 form.
We have included sample PA01 forms in the Attachments
section of this issue of the Provider
Update, and we have starred the required items for each type of request.
I. Physicians (or other professional services providers) requesting
authorization for outpatient surgery done on an inpatient basis must use the
Prior Authorization request form (PA01). This form replaces the form 158C. In addition, to expedite the review process, providers must
continue to attach the appropriate medical data to substantiate the need for the
service being provided. Any
extenuating circumstances should be submitted along with the request.
Providers should follow the instructions listed
below when completing the PA01.
NOTE: See the sample PA01
form provided. The required items
have been starred.
1.
In the block entitled Prior
Authorization Type, check the last square, 99 other.
2.
Enter the recipient's Medicaid identification number in the block
entitled Recipient ID Number exactly
as the number appears on the recipient's Medicaid identification card.
3. Enter the recipient's last name, first name, and middle initial in the
block entitled Recipient Last Name First
MI exactly as the name appears on the recipient's Medicaid identification
card.
4. Enter the seven-digit Medicaid provider number of the individual
physician making the request in the block entitled Provider
Number.
NOTE: Do not enter the
provider's group number; enter only the individual attending physician's number.
5. In the block entitled Dates of
Service, enter the anticipated dates of hospitalization in month, day, year
format (MMDDYY). If requesting post
authorization, enter the exact date of the surgery performed in the same format
(MMDDYY).
6. In the block entitled Diagnosis,
enter he ICD-9-CM diagnosis code for the primary diagnosis in the square
entitled Primary Code and Description.
If applicable, enter the ICD-9-CM diagnosis code for the secondary
diagnosis in the square entitled Secondary Code and Description.
In addition, be sure to include a narrative description of each code
listed.
7. In the space provided under the block entitled Procedure
Code, enter the current CPT-4 code for the procedure that is to be
performed, and in the space provided under the block entitled Description,
enter the appropriate description of the procedure code you entered.
8. In the block entitled Provider
Name, Address, Telephone, enter the provider's name, address, and telephone
number.
9. In the block entitled Date of
Request, enter the date the request is being made.
10. On the line entitled Provider
Signature at the bottom of the PA01 form, please ensure that the request is
signed by the provider of service or another authorized representative.
NOTE: We will accept
stamped or computer-generated signatures if they are initialed by the provider.
II.
Hospitals requesting authorization for outpatient surgery done on an
inpatient basis must use the Prior Authorization request form (PA01).
This form replaces form 158C. In
addition, to expedite the review process, providers must continue to attach the
appropriate medical data to substantiate the need for the service being
provided. Any extenuating
circumstances should be submitted along with the request.
Providers should follow the instructions listed below when completing the
PA01.
NOTE:
See the sample PA01 form provided. The
required items have been starred.
-
In the block entitled Prior
Authorization Type, check the last square, 01 Inpatient.
-
Enter the recipient's Medicaid identification number in the block
entitled Recipient
ID Number exactly as the number appears on the recipient's
Medicaid identification card.
-
Enter the recipient's last name, first name, and middle initial in the
block entitled Recipient
Last Name First MI exactly as
the name appears on the recipient's Medicaid identification card.
-
Enter the seven-digit Medicaid provider number in the block entitled Provider Number.
-
In the block entitled Dates of
Service, enter the anticipated dates of hospitalization
in month, day, year format (MMDDYY). If
requesting post authorization, enter
the exact date of the surgery performed in the same
format (MMDDYY).
-
In the block entitled Diagnosis,
enter the ICD-9-CM diagnosis code for the primary diagnosis in the square entitled Primary
Code and Description. If applicable, enter the ICD-9-CM diagnosis code for
the secondary diagnosis in the square entitled Secondary
Code and Description. In addition, be sure to include a narrative description of each code listed.
-
In the space provided under the block entitled Procedure
Code, enter the current ICD-9-CM code for the procedure that is to be
performed, and in the space provided under
the block entitled Description, enter
the appropriate description of
the procedure code you entered.
-
In
the block entitled Provider Name,
Address, Telephone, enter the provider's name, address, and telephone
number.
-
In
the block entitled Date of Request,
enter the date the request is being made.
-
On the
line entitled Provider Signature at the bottom of the PA01 form,
please ensure that the request is signed by the provider of service or
another authorized representative.
NOTE: We will accept stamped
or computer-generated signatures if they are initialed by the provider.
III.
Hospitals requesting authorization for an extension of inpatient days
must use the Prior Authorization request form (PA01).
This form replaces from 110H.E. In
addition, to expedite the review process, providers must continue to attach the
appropriate medical data to substantiate the need for the service being
provided. Any extenuating
circumstances should be submitted along with the request.
Providers should follow the instructions listed below when completing the
PA01.
NOTE:
See the sample PA01 form provided. The
required items have been starred.
1. In the block entitled Prior
Authorization Type, check the first square entitled 01 Inpatient.
2. Enter the recipient's Medicaid identification number in the block
entitled Recipient ID Number exactly
as the number appears on the recipient's Medicaid identification card.
3. Enter the recipient's last name, first name, and middle initial in the
block entitled Recipient Last Name First
MI exactly as the name appears on the recipient's Medicaid identification
card.
4. Enter the seven-digit Medicaid provider number in the block entitled Provider
Number.
5. In the block entitled Dates of
Service, enter the anticipated From
and Thru dates of the inpatient
hospitalization covered by the request.
6. In the block entitled Inpatient
Ext, check "Yes," and enter the total days requested on the line provided.
7. In the block entitled Diagnosis,
enter the ICD-9-CM diagnosis code for the primary diagnosis in the square
entitled Primary Code and Description.
If applicable, enter the ICD-9-CM diagnosis code for the secondary
diagnosis in the square entitled Secondary Code and Description.
In addition, be sure to include a narrative description of each code
listed.
8. In the block entitled Provider
Name, Address, Telephone, enter the provider's name, address, and telephone
number.
9. In the block entitled Date of
Request, enter the date the request is being made.
10. On the line entitled Provider
Signature at the bottom of the PA01 form, please ensure that the request is
signed by the provider of service or another authorized representative.
NOTE:
We will accept stamped or computer-generated signatures if they are
initialed by the provider.
IV.
Hospitals requesting both a 158C and 110H.E. at the same time should
follow the procedures listed in the following column when completing the PA01
form.
NOTE:
See the sample PA01 form provided. The
required items have been starred.
-
In
the block entitled Prior Authorization
Type, check the last square, 01 Inpatient.
-
Enter
the recipient's Medicaid identification number in the block entitled Recipient ID Number exactly as
the number appears on the recipient's Medicaid
identification card.
-
Enter
the recipient's last name, first name, and middle initial in the block
entitled Recipient Last Name First
MI exactly as the name appears on the
recipient's Medicaid identification card.
-
Enter
the seven-digit Medicaid provider number in the block entitled Provider Number.
-
In
the block entitled Dates of Service
enter the anticipated From and
Thru dates of the inpatient
hospitalization covered by the request
-
In
the block entitled Inpatient Ext,
check "Yes," and enter the total
days requested on the line provided.
-
In
the block entitled Diagnosis, enter
the ICD-9-CM diagnosis code for the primary
diagnosis in the square entitled Primary
Code and Description. If
applicable, enter the ICD-9-CM diagnosis code for the secondary diagnosis in the square entitled Secondary
Code and Description. In
addition, be sure to include a narrative description of each code listed.
-
In
the space provided under the block entitled Procedure
Code, enter the current ICD-9-CM code
for the procedure that is to be performed, and in the
space provided under the block entitled Description,
enter the appropriate description of the procedure code you entered.
-
In
the block entitled Provider Name,
Address, Telephone, enter the provider's name, address, and telephone
number.
-
In the
block entitled Date of Request, enter the date the request is being made.
-
On the
line entitled Provider Signature at the bottom of the PA01 form, please ensure
that the request is signed by the provider of service or another authorized
representative.
NOTE: We will accept stamped
or computer-generated signatures if they are initialed by the provider.
V.
Once the review process has been completed and the request has been
approved or denied, the provider of services and the recipient will receive
written notification informing them of the results.
If the request is approved, the providers should submit the appropriate
claim form and enter the nine-digit prior authorization number in the
appropriate block on the claim form. The
PA number should be entered in Item #23B on the HCFA 1500 claim form and in Item
#91 on the UB-82 claim form.
If the request is denied,
providers should follow the instructions that were provided in the August 1991 Provider
Update.
VI.
Physicians requesting an extension of outpatient visits should continue
to use the BHSF form 158-A. In
addition, physicians should attach the 158-A to the claim form if the request is
approved.