Provider Update
Volume 18, Issue 3
June/July 2001
Provider Enrollment
Effective March 1, 2001, the Department of Health and Hospitals transferred administrative responsibilities for provider enrollment to Unisys Corporation. The DHH Program Integrity Unit is responsible for oversight and monitoring.
While processing time for new enrollment and requests for changes to existing applications/requests has decreased, it still takes approximately 15 working days to process these documents. Please allow 15 working days before contacting Provider Enrollment to inquire about the status of your request.
Some procedures were revised to expedite the enrollment process. These changes include:
General
� A cover letter of explanation from the provider should be included with the application or requests for change.
� Forms must be completed in their entirety. Incomplete, inaccurate, and/or unclear applications/requests will be
returned to the requester.
� Original forms/correspondence must be mailed (faxed requests are not accepted and will be returned).
� Two-sided forms MUST BE submitted as two-sided forms.
� Applications/requests must be signed and dated with original signature (stamped signatures/initials are not
accepted).
� All requests/correspondence should be �official� meaning on letterhead with original provider signature.
� Requests concerning private practitioner provider numbers/files must come from that provider; requests concerning
facility/company provider numbers must come from an authorized representative of that facility/company.
� Requests must contain the provider number(s).
� Direct deposit requests MUST include a voided check (deposit slip not acceptable).
� Applications must include �Year End� date; if not included on the application, December will be automatically
entered on the provider file.
Linkages
� When linking or unlinking physicians to hospitals/groups, the effective date or termination date must be included in
the cover letter.
� The request must be made/signed by the physician who is officially enrolled under the number being linked.
The physician�s physical address must be his/her permanent physical location and should not be changed to the
group/facility address unless it is the physician's permanent location. The payment address need not be changed to
the group/facility address to ensure proper payments unless it is also the permanent physical location of the
provider.
Providers who change their group affiliation should notify Provider Enrollment to ensure payments are sent to the correct provider/group. Payments and remittance advices may be delayed due to incorrect mailing addresses on the Medicaid provider file.
When submitting a change of address for linkages or office relocations, the request should include:
1. A request that the provider's file be updated with current information
2. The 7-digit provider number
3. An indication of whether the change is for a physical address and/or a "Pay To" address. The request requires the original signature of the provider who is officially enrolled under the provider number (stamped signatures/initials are not accepted).
CHANGE OF ADDRESS/ENROLLMENT STATUS
It is the responsibility of the Medicaid provider to ensure that all information is current and accurate on the Medicaid provider files.
Providers should always notify the Provider Enrollment Unit when a mailing or service address and phone number change occurs. This ensures that rejected claims and correspondence reached the provider in a timely manner.
The Post Office returns excessive amounts of provider mail, including remittance advices and hardcopy checks, due to invalid or old addresses. When attempts are made to contact these providers, the telephone numbers on file are invalid in many instances. Additionally, many claims are returned to Unisys because forwarding orders at the post office have expired.
THE PE-50 FORM
When completing the Provider Enrollment Form (PE-50), providers should submit a one-page form (front and back). In other words, providers should not submit the form on two separate pages. In addition, providers should ensure that the PE-50 has an original signature. Stamped or copied signatures/initials are not accepted.
Providers who have questions pertaining to the PE-50 form may contact Provider Enrollment at (225) 923-8510.
CORRECT TAXPAYER ID INFORMATION
The Internal Revenue Service considers a Taxpayer Identification Number (TIN), also known as Employer Identification Number (EIN), as incorrect if either the name or number shown on an account does not match a name or number indicated in their files or in the files of the Social Security Administration (SSA). Each year Unisys receives an electronic tape from the IRS that shows numerous mismatches from our Medicaid provider files and the IRS files for previous years.
If the appropriate action is not taken to correct the mismatches, the law requires the agency to withhold 31% of the interest, dividends and certain other payments that it makes to your account. This is called backup withholding. In addition to backup withholding, you may be subject to a $50.00 penalty by the IRS for failing to give us your correct name/TIN combination.
An individual's TIN is his or her social security number (SSN). A provider's account should be in the name and SSN of the actual owner.
A corporation's TIN is the EIN issued to the business entity by the IRS. The name and number in the Medicaid records must match those in the IRS files.
Providers who have submitted a Form SS-4 to the Internal Revenue Service for a new EIN and have obtained a new number must mail a copy of the Notice of New Employer Identification Number Assigned to the Provider Enrollment Unit. Providers must include in the cover letter all Medicaid provider numbers affected by any such change.
TELEPHONE REQUESTS
Provider Enrollment does not give provider numbers over the telephone. A physician�s individual provider number should be obtained from that physician/provider for linkages and billing purposes when you contract with him/her to provider services at your facility. If a physician does not know his provider number, he may request it in writing, and it will be supplied in writing to him at the address on his provider file.
Effective date of linkages will also not be given over the telephone. These dates may be requested in writing either by the individual provider or the group/facility to which the physician is linked.
CONTACTING PROVIDER ENROLLMENT
All correspondence should be directed to:
Unisys Provider Enrollment
P. O. Box 80159
Baton Rouge, LA 70898-0159
Phone: (225) 923-8510
Fee Increase for Paragard Intrauterine Copper Contraceptive
Effective for dates of service on or after April 1, 2001, the fee for CPT code X0516 (Paragard Intrauterine Copper Contraceptive) was increased to $344.00.
New Codes For Certified Nurse Practitioners
RA Message 5/8/01 and 5/15/01 - FIMS # 6294
Effective for dates of service on or after June 1, 2001, Certified Nurse Practitioners with a speciality in Neonatology will be reimbursed for CPT codes 32020 (Tube thoracostomy with or without water seal), 99255 (Initial inpatient consultation; new or established patient), and 99360 (Physician Standby Services). Please note these codes are payable to only Neonatal Nurse Practitioners.
Certified Nurse Practitioners with a speciality in Women's Health will be reimbursed for CPT codes 76805 (Echography, pregnant uterus, B-scan and/or real time with image documentation; complete), 76815 (Echography, pregnant uterus, B-scan and/or real time with image documentation; limited), 76816 (Echography, pregnant uterus, B-scan and/or real time with image documentation; follow-up or repeat), 76818 (Fetal biophysical profile; with non-stress test), 76830 (Echography, transvaginal), 76856 (Echography, pelvic, B-scan and/or real time with image documentation; complete), and 59025 (Fetal non-stress test) effective the same date. CNPs with specialties in other areas should not bill these codes.
New Payable Codes
RA Message 4/17/01 and 4/24/01 - FIMS # 6272
Corrected and rerum 7/24/01
Effective with date of service April 1, 2001, locally assigned code Z9921 (Lunell Monthly Contraceptive Injection) was made payable at a fee of $21.10.
QW Modifiers Needed
Effective May 1, 2001:
CPT codes 81000 (Urinalysis), 82010 (Acetone or other keystone bodies, serum; quantitative), 86683 (hemoglobin, fecal), 87076 (anaerobic isolate, additional methods required for definitive identification, each isolate), 87339 (Helicobactor pylori), and 87899 (Infectious agent detection by immunoassay with direct optical observation, not otherwise specified) are being added to the list of procedures that require a QW modifier. Claims on which the QW modifier is not included will be denied effective May 1, 2001.
RA Message 4/10/01 and 4/17/01 - FIMS # 6223
Effective June 1, 2001:
CPT codes 82044 (Albumin; urine, microalbumin, semiquantitative), 82055 (Alcohol (ethanol); any specimen except breath), and 82962 (Glucose, blood by glucose monitoring device(s) cleared by the FDA specifically for the home) will require a QW modifier.
RA Message 5/1/01, 5/8/01, and 5/15/01 - FIMS # 6296
Increased Reimbursement for Ostomy Supplies
RA Message 4/14/01, 5/1/01, and 5/8/01 - FIMS # 6291
Effective for dates of service on or after April 6, 2001, the Bureau has increased the reimbursement for ostomy supplies (HCPCS A4360-A4421, A5051-A5149, K0137-K0139, K0278-K0280 and K0421-K0437) to 80% of the Medicare Fee Schedule, 80% of the MSRP or billed charges, whichever is less.
Modifier 59
Modifier 59 is not recogized by Louisiana Medicaid, and if appended to a surgical procedure will be denied with error code 092 (Invalid Procedure Code Modifier).
Stereotactic Procedures
Claims for Stereotactic procedures are reviewed by the medical consultants. If the procedures, as described in CPT, are not documented in the operative report and are not described as medically necessary, the procedures will be denied as included in related procedures.
Drug Utilization Review Committee Seeking Nominations
The Department of Health and Hospitals is currently accepting physician nominations for the Region 3 Drug Utilization Review Committee. The committee consists of three pharmacists and one physician who meet monthly to review profiles of drug usage from a therapeutic perspective and to provide information or clarification to the medical community. Currently, one physician opening is available. We are requesting that the nominees be Louisiana Medicaid providers who practice in at least one of the following parishes:
Acadia Allen Avoyelles Beauregard Calcasieu Cameron
Catahoula Concordia Evangeline Grant Jeff. Davis Lafayette
LaSalle Rapides Vermilion Vernon
Committee members must have time available to meet monthly for one to three hours and:
� Hold a doctor of medicine degree from an accredited U.S. medical school;
� Be licensed to practice medicine in the state of Louisiana;
� Be board certified in their speciality; and
� Be sanction free; i.e., never have been sanctioned by the State of Louisiana.
Please print or type your nomination on this form in the space provided below and return the form (brief resume appreciated) by August 31, 2001:
Unisys: Louisiana Medicaid
8591 United Plaza Blvd., Suite 300
Baton Rouge, LA 70809
ATTN: S. Delaville, Pharm.D.
LMMIS REGION THREE DRUG UTILIZATION REVIEW COMMITTEE
NAME:_________________________________PHONE:____________________________
ADDRESS:_____________________________________________________
_____________________________________________________
PARISH:________________________
I am nominating the above mentioned for consideration as a member of the LMMIS REGION THREE DRUG UTILIZATION REVIEW COMMITTEE.
SIGNATURE:_______________________________PARISH_______________________
2000 Provider Workshop Questions
The following information is the second half of the questions asked during the 2000 Provider Workshop sessions.
Ambulance Questions
1. The new policy about marking out number 3 of Attachment 2 to the Unisys 105 form and documenting the attempts to get the form signed when the physician will not sign the form allows us to be reimbursed for A0226. Is there any way for us to get paid at a higher rate of reimbursement if this trip was a true emergency?
No, there is no other mechanism to allow for higher reimbursement. If the physician refuses to sign the form, in spite of your attempts to get him to do so, you should document the attempts and bill for procedure code A0226. This procedure must be followed whether or not you consider the trip an emergency.
2. How far back can we bill for cases in which the physician would not sign Attachment 2 to the Unisys 105 form?
The claims must be received by Unisys within one year of the date of service to meet timely filing guidelines.
3. Why is attachment 2 to the Unisys 105 form required? The physician is not at the scene when the crisis occurs. By the time the physician sees the patient, the patient is often stabilized. It does not seem fair that the physician is the one who completes this form.
The Department recognizes the physician as the qualified person to determine whether the patient�s condition warranted the emergency transport.
4. If the EMT signs the run form, does he also have to sign the Unisys 105 form?
According to policy, the EMT must sign the Unisys 105 form and the appropriate attachment.
5. Does St. Jude's Hospital in Memphis follow the same policy as the Shriners Burn Unit in Texas with regard to out-of-state emergency trips across state lines?
No, DHH approval is required to transport recipients to St. Jude's Hospital in Memphis. However, DHH approval is not required to transport recipients to the Shriners Burn Unit.
6. Do we need to check with our software vendor to see if we can bill adjustments and voids electronically?
Yes, you should contact your software vendor to determine if your software will allow you to submit adjustments and voids electronically. Unisys is able to receive adjustments and voids electronically.
7. If the recipient has Medicare primary, can we bill procedure code A0226 to Unisys if Medicare denies the claim as "not medically necessary"?
Please refer to p. 4 of the 2000 Ambulance training packet. The only time providers may bill procedure code A0226 for Medicare/Medicaid recipients is if the transport is denied for a reason other than "not medically necessary."
CommunityCARE
1. Are there any recipients who do not require a CommunityCARE referral?
Recipients who do not reside in a CommunityCARE parish do not require CommunityCARE referrals. Page 56 of the 2000 KIDMED Training packet lists the categories of CommunityCARE recipients who are exempt from CommunityCARE referral requirements.
2. I am a CommunityCARE PCP. One of my patients cancels several appointments to see me in my office but then later shows up at the hospital emergency room for treatment. Must I grant a referral in this instance?
We cannot answer that question based merely on the information you have given us. According to the CommunityCARE section of the 2000 KIDMED Training packet (please see page 50), the decision to approve a referral in such a situation is based on the prudent layperson standard of the Balanced Budget Act of 1997 and takes into account the presenting symptoms of the patient, as well as the statutory definition of "emergency medical condition."
3. We are a CommunityCARE provider. We get patients who are not on our CommunityCARE list, and we cannot verify eligibility through MEVS. Can we bill these patients?
If the patients are not Medicaid patients, they would be responsible for their charges.
4. What if we verify eligibility, but the recipient is still not on our CommunityCARE list?
The MEVS and REVS systems will identify the patient's CommunityCARE PCP if there is one. If the patient has a CommunityCARE PCP, the CommunityCARE guidelines apply. If the patient has no PCP, then the CommunityCARE guidelines do not apply. There are some categories of Medicaid eligibles that do not have to be CommunityCare. Refer to the 2000 Training Packets and to the CommunityCARE manuals for the exempt categories.
5. A CommunityCARE recipient went to the hospital for an emergency situation, and the PCP said he would not give a referral because he said he has never seen the patient. The physician said the hospital would have to bill the patient. Is that true?
The decision to grant or withhold a referral must be based on the recipient's presenting symptoms and the "prudent layperson" standard. A referral should not be withheld only because the patient had not been seen by the Primary Care Physician.
6. Is the hospital responsible for giving all ancillary providers a copy of the CommunityCARE referral authorization form for emergency medical care in the emergency room?
The hospital has the responsibility to share the referral in that instance.
7. If a recipient is linked to an individual physician and the CommunityCARE referral comes in the group name, is the referral good?
The CommunityCARE referral should actually come from the individual physician to whom the recipient is linked.
8. Do CommunityCARE rules apply in other areas of the state and also for non-CommunityCARE recipients?
If he/she is a CommunityCARE recipient, those CommunityCARE rules apply statewide. If the recipient is not a CommunityCARE patient, then CommunityCARE rules do not apply to that recipient.
9. When a CommunityCARE recipient goes to the hospital for emergency care and the final diagnosis is not determined to be an emergency, does the PCP have to authorize the hospital's screening services?
According to the CommunityCARE section of the 2000 Professional Services Training packet (please see pp. 10-20), the decision to approve a referral in such a situation is based on the prudent layperson standard of the Balanced Budget Act of 1997 and takes into account the presenting symptoms of the patient. The decision to grant or withhold a referral is based on presenting symptoms rather than the final diagnosis.
Durable Medical Equipment (DME) Questions
1. Can you explain how a Medicare HMO works with Medicaid secondary?
DHH pays the Medicare HMO for services rendered to Medicaid patients, and the Medicare HMO is responsible for reimbursing the provider of service. Unisys does not process any of these claims, nor does it issue payment.
2. Can you be reimbursed for delivery charges of a rented item?
Medicaid will pay for delivery of a rented item, as long as the criteria for delivery are met.
3. I keep getting denied on wound care supplies, and the denial says I need a form from the home health agency. There's no home health agency involved. What do I do?
Since this question involves a specific case, please contact the Unisys Prior Authorization Unit at (800) 488-6334 to discuss the denial you are receiving and to obtain clarification on what is required.
4. What if we run out of the supplies before the end of the prior authorization (PA) period?
In such an instance, the provider should request a reconsideration of the original PA to include the additional supplies.
5. Medicaid doesn't cover portable oxygen. Can we bill the patient for that?
Yes, you may bill the patient for this particular item.
6. Regarding wound care, who decides what is authorized as far as quantities? Who is supposed to estimate the quantity of tape, number of gauze bandages, etc.?
In requesting the quantities for prior authorization purposes, the provider estimates the patient�s need based on the physician's prescription or order. If it appears that the quantities requested are not supported by the patient's diagnosis or condition or by other documentation, the approved quantities may be less than those requested.
7. Why are Foley catheters only payable through the Pharmacy Program?
Any questions regarding Medicaid policy should be directed in writing to the Bureau of Health Services Financing Program Operation Section or Pharmacy Benefits Management Section, at P. O. Box 91030, Baton Rouge, LA 70821-9030.
8. Has criteria for glucose monitors changed lately?
The criteria by which requests for glucose monitors are evaluated has not changed.
9. It was stated that a provider can appeal an approved service. We were told by the Prior Authorization Unit that the recipient had to initiate the appeal. Which is correct?
The answer to this question is a question of semantics. Providers may request a reconsideration of a denied prior authorization request. This process is described in the DME provider manual and involves the provider and the Unisys Prior Authorization Unit. Only recipients may appeal a decision made about a prior authorization request, which is a formal process involving a hearing before an administrative law judge.
10. Is DHH considering changing the ICF-MR rule through the litigation you mentioned earlier?
Unisys has not been informed of any plans by DHH to change the ICF-MR rule.
11. Do I have to wait until the baby gets an ID number in order to request a prior authorization?
If the situation is an emergency (pending discharge, for example), the Unisys Prior Authorization department can consider the request for medical review and issue a PA letter that indicates that criteria have been met but that the PA cannot be approved until a valid Medicaid number is supplied by the provider. The provider would then need to have the PA updated with the correct Medicaid ID number in order for the recipient's claims to be paid.
12. In the instances in which the PA department will consider a change in PA dates, is it optional to change the PA dates if they don't match our actual delivery date?
This is an option given to providers (not a requirement) as detailed in pp. 42-43 of the 2000 DME Provider Training packet.
13. Is the Community Care referral number required for DME claims?
The Community Care referral number must be entered in item 17A of the hardcopy HCFA-1500 claim form or as data element 33 in electronic claims .
14. We provided a customized wheelchair to a recipient in a nursing home. When we filed the claim to Medicaid, we got denied because the recipient has Medicare and a Medicare supplemental insurance. We know Medicare won't cover this service, but the Medicare supplemental insurance won't give us an EOB unless we file to Medicare first. Is there any way to avoid having to go through all this paperwork?
There is no way to circumvent this requirement. If Unisys requires that the claim be filed with the Medicare supplemental insurance prior to processing the claim, then the provider will need to follow the guidelines of that supplemental insurance in order to be able to file to Medicaid.
15. If the TPL carrier shown on the Unisys files refuses even to process our claim to produce an EOB, what can we do?
If the TPL carrier will not assist you, you may contact the TPL Unit at DHH by calling (225) 342-9250.
16. If one of the procedure codes that is supposed to bypass the Medicare edit is still being denied for error code 275, what can we do?
Please submit the claim and a copy of the RA page showing the denial to the Unisys Correspondence Unit at P. O. Box 91024, Baton Rouge, LA 70821. Please include a cover letter stating the problem and asking for assistance in getting the claim paid.
17. Does PA have access to old records about the patient to help establish that the patient meets criteria for a current request?
The Unisys Prior Authorization department cannot access old prior authorization requests to assist in meeting criteria on a current request. It is the provider's responsibility to obtain and submit required documentation when making a prior authorization request.
18. When TPL is involved and the other insurance pays nothing, should block 29 the HCFA-1500 be left blank or entered as $0.00?
If the private insurance pays nothing, $0.00 should be entered in block 29 of the claim form.
19. If the patient over 21 is receiving some kind of oxygen that is not covered by Medicaid, but they also receive Medicaid covered items from us, can we bill Medicaid for the covered items and bill the recipient for the non-covered items?
In general, Medicaid recipients may be billed for items non-covered by Medicaid. This is not negated by the fact that the provider receives payment for items covered by Medicaid.
20. With respect to customized wheelchair seating evaluations, is the nursing home responsible for obtaining the evaluation?
Please refer to the policy documented on p. 15 of the 2000 DME Training packet. It is not the responsibility of the nursing facility to obtain the evaluation. However, it may be the responsibility of the nursing facility to transport the recipient to an outpatient rehabilitation therapy facility in order for the evaluation to be done.
21. If an IV pump purchase is authorized for a patient and the patient breaks it, can we request a new pump?
The provider may submit a request for a new item in such a circumstance. The request must contain documentation as to why the request is being made, including a statement that the patient broke the item and any available information regarding the circumstances under which the breakage occurred.
22. What if such a request is denied?
Any denied prior authorization request may be submitted for reconsideration by the provider or for appeal by the recipient. If the provider does not understand the reason for the denial, he may contact the Unisys Prior Authorization unit to obtain clarification. Finally, the recipient may appeal the decision as mentioned in question 9 above.
23. Can waiver recipients also receive DME?
Waiver recipients may receive DME as long as it is medically necessary and meets the same criteria that apply to any other Medicaid recipient.
24. Effective 10/1/00, Medicare has stated that DME can no longer provide wound care-only home health providers can. Will Medicaid follow this guideline also?
DHH has no plans to implement this policy for straight Medicaid recipients.
25. We have received approval for an apnea monitor. When we submit a request for an extension by the date indicated on the PA letter, the request is denied stating that the data is not up-to-date enough. How do we deal with this problem?
In these instances criteria must be as up-to-date as possible. Providers may have to submit the extension request closer to the date on which the PA expires in order to have recent documentation to submit.
26. When an extension is requested, do we have to send in all the original documentation with the extension request?
It is not necessary to send in all the original documentation with a request for an extension. An extension request requires a PA01 form and any other documentation substantiating the need for additional supplies or an extension of the span date of the prior authorization.
27. Do we need to obtain prior authorization for tube feeding for a Medicare/Medicaid recipient?
If the items or supplies are not covered by Medicare but are covered by Medicaid, it is necessary to obtain prior authorization from Medicaid. If the items or supplies are covered by Medicare, then no prior authorization is necessary, and the claims for those items or supplies will be filed to Medicare first.
28. If supplies are authorized for a 3-month period and the recipient wants all the supplies at one time, can we give those to the patient at one time?
Providers are normally to dispense supplies a month at a time. This is also for the provider's protection in case the recipient loses eligibility later during the prior authorization period. There would have to be some extenuating reason why the recipient should receive the supplies all at one time.
29. If a Medicaid rental changes to a purchase and the recipient cannot be located to give them a new item, what can we do?
You may not bill Medicaid for the new equipment unless it is actually delivered and the recipient signs the delivery ticket verifying delivery.
30. When emergency requests occur on the weekend when Unisys is closed, should we go ahead and deliver the service or should we wait until Unisys opens on Monday?
There is no definite answer to this question. Each provider must decide in such a situation whether he wants to deliver the service or not. DHH would encourage providers to consider the patient's well being as paramount and to act accordingly. However, there is no requirement that the provider go ahead and deliver the service prior to obtaining prior authorization. Providers often are more willing to provide services under such circumstances if they have become familiar enough with the criteria for the particular service to be confident that the service would meet criteria and would eventually be approved.
31. If we have a nursing home recipient who does not have Medicare and who is tube-fed, can we still supply that service?
The service may be supplied as long as the specific criteria are met and prior authorization is approved by Unisys.
32. If we provide hearing aids, must we provide the batteries?
You would not be required to supply the batteries, but it might be more convenient for the recipient if he obtained both the hearing aid and the batteries from the same source.
33. There is no specific procedure code for hearing aid batteries. How would these be billed?
A new code, Z9311, is to be established for hearing aid batteries.
34. Does Medicaid cover hearing aids?
Medicaid covers hearing aids for recipients under age 21 subject to prior authorization and the criteria listed on p. 7-18 of the DME provider manual.
35. I have a 275 denial for a procedure code that's supposed to bypass the Medicare edit. It's only happening on some patients. What should I do about this?
There are some procedure codes that only bypass the 275 (Medicare) edit only if the recipient resides in a nursing home. You will want to make sure the procedure code is not being denied because of this specific reason. If that is not the case, please submit the claim and a copy of the RA page showing the denial to the Unisys Correspondence Unit at P. O. Box 91024, Baton Rouge, LA 70821. Please include a cover letter stating the problem and asking for assistance in getting the claim paid.
36. How do we tell if a recipient is a QMB or has Medicare and Medicaid but is a non-QMB?
The messages returned by REVS and MEVS indicate this (please see p. 15 of the 2000 Basic Training packet). Pure QMB recipients are indicated by the following message: "This recipient is only eligible for Medicaid payment of deductible and co-insurance of services covered by Medicare. This recipient is not eligible for other types of Medicaid assistance." Dual QMB recipients are indicated by the following message: "This recipient is eligible for Medicaid payment of deductible and co-insurance of services covered by Medicare." Non-QMB recipients have no corresponding message, but it is indicated that they have Medicare Part A and/or Part B.
37. How do we tell if the recipient has other insurance?
The messages returned by REVS and MEVS indicate that the recipient has other insurance.
38. We have received denials for claims for a patient in hospice. Can these claims be paid?
Providers receiving this type of denial for services unrelated to the terminal diagnosis of the patient should submit their claims with a cover letter requesting consideration of the claims to the DHH Hospice Program Manager, P. O. Box 91030, Baton Rouge, LA 70821-9030.
39. How do we know if a patient is in hospice?
The nursing home in which the patient resides will know if the patient has transferred to hospice and will be able to verify that information.
40. Is there any way that PA information and a listing of PAs can be available on REVS/MEVS?
There are no plans to include prior authorization information on the MEVS/REVS system. Prior authorization information is conveyed to providers by prior authorization letters. A prior authorization letter is mailed out any time a prior authorization request is considered, whether it is an initial request (approved or denied) or a reconsideration.
41. Can we get PAs that span dates up to a three-month period and not have to request a new PA each time we give out supplies?
Prior authorizations for most ongoing items or supplies may be requested for up to a six-month period.
42. Do prescriptions have to have an original physician's signature? Will a stamped or computer-generated signature be acceptable?
Physician signatures must either be original signatures or, in the case of verbal orders recorded using a stamped physician's signature, the signature must also be signed with the full name and credentials of the nurse taking the order.
43. Does the delivery ticket have to be signed by the recipient or responsible party, or someone with power of attorney? Can anyone else sign the delivery ticket?
The delivery ticket may be signed by a responsible party or one with power of attorney if the recipient is unable to sign the delivery ticket.
44. Can we submit adjustments and voids electronically?
Electronic adjustments and voids of DME claims are accepted by Unisys.
45. Are adjustments done on the HCFA-1500 form?
Adjustments to paid DME claims are done on the Unisys 213 form, which is available at no charge from Unisys. The letters "DME" must be written at the top of the Unisys 213 form to indicate the adjustment is for a DME claim.
46. We have a patient who is abusive of the equipment we supply. We have requested repairs and replacements and have not been paid for all services. Is there any avenue to resolve a case like this?
You may report the situation by using the toll-free fraud & abuse hotline established by DHH to report abuse of Medicaid services. The telephone number is (800) 488-2917. Regarding payment for the services, we would need more information to assist you, such as whether the PA request was denied, or if the actual claim was denied, or what may be causing your claim denials. Our Provider Relations Telephone Inquiry Unit can assist you if you can provide more specific information.
47. Must we have a certificate of medical necessity for Medicaid?
The certificate of medical necessity (CMN) is a form required by Medicare but is not required by Medicaid.
48. We have some wheelchairs in nursing homes that do not appear to be taken care of and are in need of repairs. How do we obtain PA to fix these wheelchairs?
For each wheelchair, a request for repairs should be submitted using the PA01 form and supporting documentation showing the condition of the wheelchair, which repairs are to be done, and the cost of the repairs.
49. What criteria are needed to get approval for an electric wheelchair?
You may refer to p. 25 of the 2000 DME Training packet for requirements for electric wheelchairs.
50. We have a patient who is getting home health. Can we still provide a wheelchair to this patient, even though the recipient is getting home health?
The fact that the recipient is receiving home health does not prevent the recipient from receiving DME; therefore, you may provide the recipient a wheelchair provided all criteria are met.
KIDMED Questions
1. If a patient comes into our office but is not on our RS-0-07, how do we handle them? May we see them for a KIDMED screening?
The provider should contact Birch & Davis to ascertain whether or not the child is linked to another provider. If the child is linked to another KIDMED provider, you will not be reimbursed for screening that child. If the child is not linked to a KIDMED provider, you may be reimbursed for screening the child if the child is currently due for a screening. If the child's parent wants to have the child linked to you as his KIDMED provider, the parent should request that of Birch & Davis.
2. We called to find out if a child was linked to us as their KIDMED provider, but Birch & Davis would not tell me the name of the provider to whom the child was linked. Is this correct procedure?
Yes, this is correct procedure. Birch & Davis staff can tell you if the child is linked to you or if the child is linked to another KIDMED provider. The recipient (or recipient's parent) may contact Birch & Davis to ascertain the KIDMED provider to whom the recipient is linked.
3. We are contracted with a PCP to perform screenings on some of his patients. Let's say that we perform a hearing screening and detect a problem for which we refer the child back to his PCP. Can we subsequently bring the child back in for a hearing screening and a nurse consult to follow up on the problem?
You may bill for performing a hearing screening again. If services are performed that support billing the nurse consult, the nurse consult may be billed in addition to the hearing screening.
4. We have a patient in Alexandria who needs visits at LSU in Shreveport. I have trouble finding anyone to transport the child to Shreveport. Who should I contact for assistance?
The Medical Dispatch office will assist in scheduling non-emergency medical transportation for Medicaid recipients. The phone numbers for Medical Dispatch are listed in the Medicaid Services chart in the back of all the 2000 training packets.
5. On the KM-3 claim form, there is a place to indicate "transportation assistance needed." Does this refer to Medicaid-covered transportation?
That field on the claim form was used at one time to indicate the need for Medicaid transportation. However, the field is no longer used to request Medicaid transportation. If Medicaid transportation is required, it should be requested directly through the Medical Dispatch office (see question 4 above).
6. Is KIDMED a mandatory program for Medicaid recipients under the age of 21?
KIDMED is not a mandatory program-recipients have the right to choose to participate in the program. Children under age 21 who are CommunityCARE recipients are automatically enrolled in KIDMED, but they cannot be forced to appear for screenings and follow-up care.
7. If a child is not a KIDMED participant, can he be screened through the EPSDT program?
Children under age 21 who do not participate in KIDMED may be screened by a KIDMED provider. KIDMED is a component of the EPSDT program, but it should not be confused with EPSDT Health Services, which are provided by school boards and Early Intervention Centers.
8. If a child comes into our rural health clinic for a KIDMED screening, can we charge for a core visit on the same day if we make an internal referral?
Medicaid will not pay for both a KIDMED screening and a rural health clinic encounter (core visit) on the same date of service by the same billing provider.
9. If a child comes in for a well child visit and is not linked to a KIDMED provider, can we do a KIDMED screening on the child?
Yes, children under age 21 who do not participate in KIDMED may be screened by a KIDMED provider when a screening is due. Providers may contact the KIDMED hotline at (800) 259-8000 to obtain linkage and screening information.
10. If a child comes in and we perform a well child visit, and then later the child appears on our RS-0-07 for the first time, how soon should we bring that child in for his initial screening?
The timelines indicated in the 2000 KIDMED Training packet on p. 5 still apply in this case. How soon you need to perform an initial screening depends on the age of the child.
11. Can foster children be linked to KIDMED providers?
Foster children are not excluded from participating in the KIDMED program. However, they are exempt from CommunityCARE.
12. Is there any instance in which a child under age 21 who is eligible for Medicaid would not be eligible for KIDMED?
We are not aware of any reason a child under age 21 would not be eligible for KIDMED.
13. Is a child born to a Medicaid-covered mom eligible for Medicaid from birth?
A child born to a Medicaid mom is considered Medicaid eligible for the first year of life. However, the child must still be assigned a Medicaid ID number by the parish Medicaid office.
14. Can Vaccines for Children (VFC) vaccines be used for non-Medicaid recipients?
As the Medicaid program does not set policy for non-Medicaid recipients, that question should be directed to the VFC program.
15. We performed a KIDMED screening on a child after verifying that the child was on our RS-0-07 for that month. However, the claim was denied indicating that the child was linked to another provider for that date of service. How can we be paid?
Please contact Birch & Davis regarding the linkage of the child. Once the linkage issue has been resolved, the claim may be resubmitted to Unisys for processing.
16. Are there diagnosis restrictions on immunization procedure codes?
There are no specific diagnosis codes required for immunization procedure codes.
17. We are trying to bill the "X" consultation/counseling codes, but our electronic claim clearinghouse is not allowing us to bill these procedure codes. What should we do?
Medicaid accepts billing of these codes electronically. Since it is your electronic claim vendor who is preventing the claims from being billed, you should contact the vendor/clearinghouse directly regarding the problem. Remember that these codes are not billed in the same format as the KM-3 screenings.
18. We billed for all three screenings (medical, hearing, and vision) for a patient and were paid for all three. However, we later determined that only the medical screening was performed. How do we give the money back for the hearing and vision screenings?
The paid claims for the hearing and vision screenings should be voided using the KM-3 form. Each paid claim line (i.e., each different screening) should be voided on a separate KM-3. The KM-3 should be completed just as the original claim line was billed, except that the "void" box will be checked in item 1, a reason code will be indicated in item 2, and the ICN of the paid claim will be indicated in item 3. Page 39 of the 2000 KIDMED Training packet details completion of KM-3 adjustments and voids.
19. We billed for the wrong child within a family (not the child on which the screening was performed). By the time we realized the error, the sixty-day filing limit had elapsed. Can we still be paid for the screening on the correct child?
According to DHH, all KIDMED screening claims must be received by Unisys within 60 days of the screening date in order to meet timely filing guidelines. Any claim that is not received within 60 days of the screening date will be denied for timely filing.
20. How do we complete the referral section of the KM-3 if we do not know a specific date and time of the referral?
In such instances the provider should estimate a referral date and time to be entered on the KM-3.
21. The physician in our practice had seen a patient as a private pay patient and had to write off an unpaid balance as bad debt when the patient would not pay. Later the patient becomes covered by Medicaid and wants to choose our physician as his PCP. Because of the prior problem with this patient, our physician does not want to accept the patient. Is this permissible?
It is permissible for a PCP to refuse to accept a patient who chooses him. The provider must notify Birch & Davis immediately so that the recipient can choose or be assigned another PCP.
22. Who can request an interperiodic screening on a child?
An interperiodic screening may be requested by anyone outside of the formal health care system, including family members, school officials or personnel, clergy, and community contacts.
23. If a nurse practitioner is performing a medical screening, which type of code would we bill for the service?
The "medical screening nurse" code should be used for such an instance.
24. When we billed code X0187 performed by a nurse practitioner and used her Medicaid provider number as the attending number, the claim denied stating that she was not certified for the procedure. Why?
This denial is caused because nurse practitioners may bill and be reimbursed for certain procedure codes as part of the Professional Services program within Medicaid, and nurse practitioners may also perform KIDMED services as part of the KIDMED program within Medicaid. The KIDMED screening codes are not set up in the claims payment system to be paid directly to nurse practitioners. However, KIDMED screenings may be performed by nurse practitioners. If the screening is performed by a nurse practitioner, the attending provider number field (item 7 on the KM-3 form) should be left blank. This will prevent the claim from denying for error code 210 as you have described.
25. Is it true that a KIDMED clinic must be supervised by a physician?
KIDMED provider enrollment requirements are addressed in the KIDMED provider manual on pages III-1 through III-4. In general, at least some level of physician involvement is required in that one requirement for enrollment as a KIDMED provider is the agreement to retain a medical director who is licensed to practice medicine in Louisiana and has a medical degree from a college or university accredited by the American Medical Association. It is not necessary that a physician always be present on-site at a KIDMED clinic.
26. When the training packet states that the consult codes are not to be used for ongoing therapy, how is ongoing therapy defined?
Ongoing therapy is defined as therapy of longer than six weeks' duration.
27. If we conduct Head Start physicals, can we bill them as interperiodic screenings?
Head Start physicals may be billed as interperiodic screenings if all components of a medical screening are conducted. The name of the person requesting the physical and the reason for the physical should be noted in the patient's chart.
28. Can the "X" consult codes be billed by a physician for a patient who is an established patient?
The consultation/counseling codes may be used to bill for services provided to an established patient.
29. Is any of the information on the EP-0-21 based on information we complete on the RS-0-07?
The EP-0-21 is generated only to those providers who choose to have Birch & Davis schedule appointments for them. Certain items of information indicated on the RS-0-7, such as future appointment dates, are used to produce the EP-0-21.
30. If referral assistance is not needed, should the referral section of the KM-3 still be completed?
The referral section of the KM-3 should always be completed if a referral offsite or in-house has been indicated in item 32.
31. May we give Rocephin shots in the office even if it is only covered under the pharmacy program? May we bill the patient for the injection?
Louisiana Medicaid only covers Rocephin as a pharmaceutical provided through the pharmacy program. Physicians may write a prescription for the medication, which the recipient would then have filled at a Medicaid pharmacy. The recipient may bring the Rocephin as dispensed by the pharmacy to the physician's office for injection. The physician may bill the Medicaid program a low-level office visit (procedure code 99211) for the administration of the injection. If the injection is administered during the course of a more complex office visit, the appropriate code for that visit could be billed. Please note that the office visit claim would be considered under the Professional Services program rather than as a KIDMED service.
32. Some of our patients have both Medicaid and other insurance, but we know the other insurance won't cover the immunizations we bill. Can we still give those patients immunizations from our VFC stock?
As that question involves policy established by VFC, please contact the VFC program for clearance on that issue.
Long Term Care Questions
1. We are receiving denials that state no 51-NH is attached to the TADs, but we are certain the 51-NH forms were attached to the TADs when we mailed them. What can we do about these instances?
Providers with questions regarding the physical handling of their TADs (including attachments sent with TADs and items not keyed) may contact the Unisys Long Term Care department at (225) 237-3259.
2. When billing leave days for a recipient who has not been discharged, must I calculate in the "TO DAY" and "TOT DAYS" fields the number of days for which I am seeking payment?
If leave is reported and the recipient is not being discharged, the provider need not calculate corrected entries for the "TO DAY" and "TOT DAYS" fields. When the claim is processed, the Unisys computer system will calculate the number of leave days that should be paid and will make payment accordingly. If leave days are reported in excess of the allowed days for that type of leave, the computer system will make payment only for the allowed days and will "cut back" the total payment accordingly.
3. We are rebilling for service dates that are not yet a year old but are being asked to resubmit with a copy of the remittance advice (RA) page from the original denial. Is this correct?
Additional documentation is being required when claims are being resubmitted after being denied. When a denied claim is resubmitted, the provider should include a copy of the RA page showing that the claim denied and why it denied.
4. How can we apply to be a DME provider?
The Unisys Provider Relations Telephone Inquiry Unit at (800) 473-2783 accepts requests for provider enrollment packets, which are mailed out at no charge.
5. Are the emergency rules published early in 2000 accessible on the Internet?
Emergency rules are published in the Louisiana Register, which can be located on the Internet.
6. Must we discharge the patient if he exceeds the allowed number of leave days?
Unless the absence exceeds 30 consecutive leave days or the patient is admitted to a hospital's skilled nursing unit, it is not necessary to discharge the patient just because he exceeds the allowed number of paid leave days.
7. If a recipient leaves the facility for less than 24 hours, returns to the facility and then leaves again, should the initial absence be reported?
Absences that are less than 24 hours' duration should not be reported as leave.
8. How would we adjust an adjustment?
Long term care adjustments are filed on the Unisys 212 form. When adjusting an adjustment, the internal control number (ICN) of the adjustment should be entered in item 16 of the Unisys 212 form.
9. Our supplemental billing seems to take a long time to appear on a remittance advice. What causes it to take so long?
Supplemental billing received during the last week of the month is held and processed with the next month's regular TAD, which may result in a longer processing time than normal.
10. We have been trying to drop a recipient from our TAD for three months. How do we go about this?
To delete a recipient from the TAD, the provider must enter the code "D" in the Action Code field of the TAD form. This should prevent payment for that month and should prevent the recipient from appearing on the following month's TAD.
11. Do we need to draw a line through the line item of the recipient we are trying to drop from the TAD?
That is not necessary, but it is acceptable.
Professional Questions
1. Is there a field representative for Tangipahoa pPrish?
At this time there is no field representative assigned to that parish. However, providers in that area requiring a field visit should call the Provider Relations Telephone Inquiry Unit at (800) 273-4783 and request a field visit. Such requests are distributed by the department manager to available field analysts. Once a field analyst is assigned to that territory, his/her name will be published in the provider newsletter and/or a remittance advice message.
2. Does the signature in block 31 of the HCFA-1500 have to be the physician's signature, or can it be someone else's?
The signature in block 31 may be that of any person authorized by the provider to sign the claim forms.
3. Do you have to bill your recipients in alphabetical order?
There is no requirement that claims be billed in alphabetical order by recipient name.
4. Does Medicaid have a web site?
Currently there is no web site that contains Louisiana Medicaid policy and procedures documentation. However, the Department of Health and Hospitals (DHH) does have a website, which is www.dhh.state.la.us.
5. When you have to submit a claim with additional information, what P.O. box do you send it to?
In general, claims are submitted according to the list published in all 2000 training packets. There may be specific instances in which certain claims may be submitted to a different post office box. Such specific exceptions would be noted in the provider manual or training packet for the physician's program. Physician and professional services claims (excluding crossovers) should be submitted to P. O. Box 91020, Baton Rouge, LA 70821.
6. What is the correct address for paper crossover claims?
The correct address for hardcopy crossover claims is P. O. Box 91023, Baton Rouge, LA 70821.
7. Does Medicaid payment of crossovers depend on what Medicare pays?
Payment of crossover claims is determined in part by the amount that Medicare pays on the claim.
8. How is Unisys handling Medicare HMO claims?
Unisys does not process Medicare HMO claims. The TPL Unit of DHH has been working with Medicare HMOs to develop a process by which the HMOs are paid directly and are responsible for distributing payment to the individual providers.
9. Can we get a list of covered lab codes?
The 2000 fee schedule was mailed out to providers in October, 2000. Providers who did not receive one may request one from the Unisys Provider Relations Telephone Inquiry Unit at 1-800-473-2783.
10. Why are procedure codes 84443 and 84479 being denied?
These codes are subject to laboratory panel code edits. It is possible the codes are being denied for this reason. Providers with specific denials they do not understand may contact our Provider Relations Telephone Inquiry Unit for assistance.
11. Lab charges are denying due to diagnosis not justifying lab work. Why is this?
In general, Medicaid claims are not subject to diagnosis editing. There are a few specific exceptions, such as the UTI diagnosis requirement for urinalysis performed on a pregnant recipient (see p. 40 of the 2000 Professional Services Training packet). Without knowing the specifics of the claims, it is impossible to say exactly why the claims are being denied. If you can give us more specific claim information, we can research the denials and assist you.
12. As an independent laboratory facility, our tests are done and returned to the physician before billing is done. We have encountered different facilities that don't accept Medicaid and therefore don't send referrals and refuse to obtain them. What is our recourse? Can we have something in writing to send them that they are responsible? What else can we do?
If a non-Medicaid physician sends a CommunityCARE recipient's sample to a Medicaid laboratory for testing, the Medicaid laboratory may request a referral directly from the recipient's PCP. If the referral is not granted, the recipient is responsible for the charges.
13. Do we need to enter the pre-certification number on our claim for the physician's inpatient services? Why did we receive a 171 denial on our claim?
It is not necessary to enter the hospital pre-certification number on the physician's claim form. However, there must be a pre-certification on file in order for the physician's claim to be paid. If no pre-certification was obtained by the hospital, or if the pre-certification request was denied because it was not filed timely, the physician's claim should be submitted with the admit and discharge summaries to the Unisys Correspondence Unit at P. O. Box 91024, Baton Rouge, LA 70821. A cover letter should be attached requesting a pre-certification override.
14. Why are we getting ongoing 171 denials when we verify the pre-certification number with the hospital?
Without looking at the specifics of your denials, it is not clear why you would receive such denials. If you contact us with specific information, we will be able to determine the cause of the denials and the solution to the problem.
15. How do you bill Medicaid when Medicare is primary and requires modifiers?
In general, crossover claims are billed to Medicaid exactly as they were billed to Medicare.
16. What is the appropriate modifier to use when we see a patient for an office visit and perform a procedure on the same day?
Medicaid does not require a specific modifier in such an instance. Payment of such claims may be affected by the global surgery period policy.
17. Do you need to send an operative report with a claim billed using the -51 modifier?
Claims including the -51 modifier should be filed with the operative report attached.
18. What can we do if our surgeon uses modifiers correctly to indicate post-op care and the other surgeon billed his claims wrong, keeping our surgeon from being paid correctly?
In such a case you would need to contact the other provider to have him adjust his claim. Once that is done, you may resubmit your claim for payment.
19. We put modifier -51 on our claims and sometimes the modifier doesn't show up on our RA. What causes this?
If the claims are billed electronically, then the modifier is not being transmitted in the proper fields. If the claims are filed hardcopy, it is possible that the modifiers are not being keyed correctly by Unisys Data Entry. When you have these appear on your remittance advice, call the Provider Relations Telephone Inquiry Unit at 1-800-473-2783 and ask the phone representative to retrieve the claim from microfilm. The phone representative can verify from the microfilmed copy whether or not the modifier was on the claim form. If the modifier was on the claim form and was not keyed, the phone representative may be able to resubmit the claim for you. If that is not the case, you will be asked to correct the claim and resubmit.
20. How many modifiers does Unisys accept on electronic claims?
The specifications for professional services claims allow two procedure code modifiers to be appended to a procedure code.
21. We have a recipient who has other insurance according to the Medicaid files. We have sent a claim in with a letter from the other insurance company showing there is no coverage, and we got the claim paid. However, the next claim we filed on that patient denied saying he had other insurance.
When a request such as this is received by the Correspondence Unit, the request to terminate the other insurance is forwarded to DHH, who has the authority to correct TPL files. In the meantime, the Correspondence staff can forward the claim sent with the request to processing with an override of the TPL edits. However, until the TPL file is actually corrected by DHH, subsequent claims will not automatically be overridden and will be subject to TPL edits. The provider may continue to submit subsequent claims to Correspondence with proof that the other insurance has terminated, and these must be accompanied by a cover letter requesting override of the TPL edits.
22. How can TPL be removed from a patient's file?
The most direct method for this is for the recipient to initiate this through his local Medicaid office. In addition, the provider may send documentation showing that the TPL has ended to the Unisys Correspondence department with a letter requesting that the TPL be removed. Such requests are then forwarded to the DHH TPL Unit, which has the authority to update and correct any errors in the TPL files.
23. If there is incorrect TPL information on a recipient's TPL file, how can we have this corrected?
The recipient should contact his parish Medicaid office to have the corrections made. Otherwise, you may send the correct information (a letter showing the TPL has ended, an EOB showing no coverage, an EOB showing coverage by a different insurance company, etc.) to the Provider Relations Correspondence Unit with a cover letter requesting that the recipient's TPL file be updated.
24. We have contacted the parish office to have the TPL file updated, but the update is not showing on the Unisys TPL files.
There is a brief lag time between the date the files are changed at the parish office and the dates these updates are loaded to Unisys files. If the discrepancy persists, please send documentation of the TPL correction to the Provider Relations Correspondence Unit.
25. We are in a clinic setting, but each physician bills independently. We are employing a nurse practitioner. Should we obtain a group number and have the nurse practitioner linked to the group number?
DHH requires that nurse practitioners obtain an individual provider number. A further requirement is that claims billed by a physician for nurse practitioner services list the nurse practitioner's individual number in block 24K of the HCFA-1500 claim form. If your physicians are set up to bill their own claims, you may have the nurse practitioner's Medicaid number linked to the Medicaid number of each physician that will be billing for the nurse practitioner, or you may obtain a group number for all the physicians and then link the nurse practitioner's Medicaid number to that group number.
26. Would a person diagnosed with hepatitis and receiving treatment every three months be eligible for an extension of physician visits?
According to the guidelines for physician office visit extensions, "extensions will be granted only for emergencies, e.g. trauma; life-threatening conditions; life-sustaining treatments, e.g. chemotherapy for malignant diseases or radiation therapy." You should submit the 158-A extension request with whatever documentation is available to show that your case meets extension criteria.
27. If a claim is denied with error code 429, can we bill the patient?
This error code indicates that the service rendered is not covered under the medically needy eligibility category. As the service is non-covered, it may be billed to the recipient.
28. Can we bill the patient when we receive a 996 error code?
Providers may not bill the recipient for claims that are approved with the 996 code. The 996 code indicates that the claim was approved by Medicaid-not denied-and that payment was made according to cost-comparison of Medicare's payment and Medicaid's allowed amount. If Medicare has paid more than Medicaid allows, the claim is considered approved but is paid at $0.00. Because these claims are considered approved, the recipient cannot be billed.
29. For J code injections (J1040) that are not covered, can I seek reimbursement for serum, syringes, etc.? Is it true that recipients can purchase serum (Depomedrol) from a pharmacy and the pharmacy get the reimbursement?
In general, providers may seek reimbursement from recipients for services that are not covered by Medicaid. If Depomedrol is covered under the pharmacy program, then recipients should be able to obtain it at a participating Medicaid pharmacy if the doctor will give them a prescription. The cost of supplies is included in the fee for the office visit.
30. Can a physician bill for a newborn without it having a number?
A claim can be processed only if it contains a 13-digit Medicaid ID number. If there is no number for a newborn, it is impossible to bill a claim for the newborn. Some providers submit such claims with the baby's name and the mother's Medicaid number to establish timely filing, knowing the claim will be denied for name/number mismatch.
31. Does Medicaid cover flu shots?
Medicaid covers flu shots provided to recipients under age 21.
32. For intrathecal baclofen therapy, is reprogramming of the pump covered?
Reprogramming is covered, as indicated on p. 39 of the 2000 Professional Services Training packet.
33. Is there still a limit of 1 per 180 days on the audiology codes?
The limits on audiology codes as published in the October 1996 provider newsletter are still effective.
34. Does the delivering physician use modifier -24 for anesthesia? We have a delivering physician not getting paid when billing for anesthesia.
If the delivering physician introduces the epidural for a vaginal delivery, he is supposed to bill 62319 with modifier to obtain the fee for this service.
35. Can a physician be paid for conscious sedation?
A physician can be paid for conscious sedation, provided all guidelines regarding the procedure are followed. These guidelines are detailed on p. 14 of the 1999 Professional Services Training packet.
36. Can we bill electronically for conscious sedation?
As the guidelines state, claims for conscious sedation must be billed hardcopy with documentation for medical review, and so claims billed electronically will be denied.
37. We had a patient who went into surgery with anesthesia beginning as an epidural and then changing to general anesthesia during the surgical session. How should this be billed?
If the epidural was administered and then general anesthesia had to be administered, both the epidural and the general anesthesia may be billed. The general anesthesia minutes would begin when the general anesthesia was administered-not when the epidural was administered.
38. You're now paying for nurse practitioners for assistant-at-surgery services, but you won't reimburse physician assistants for the same services?
According to the policy published by DHH, assistant-at-surgery services will be payable to nurse practitioners and clinical nurse specialists.
39. Regarding the documentation required for assistant-at-surgery reimbursement for nurse practitioners, is this also required for nurse practitioners to do procedures in a physician's office?
The documentation required to approve nurse practitioners for assistant-at-surgery reimbursement does not stipulate any particular location in which the services would be performed. If the procedure is of such complexity to require assistant-at-surgery services, then the documentation listed on p. 51 of the Professional Services Training packet would be required in order for reimbursement to be made.
40. Are some J codes edited for diagnosis?
In general, procedures are not edited for diagnosis. However, you may contact Provider Relations Telephone Inquiry Unit for assistance if you receive a denial due to diagnosis restriction.
41. Can you be paid for an office visit on the same day as a procedure?
The answer to this question depends on what the procedure is. If the procedure is on the global surgery period (GSP) list, the answer is "no." However, if the procedure is not GSP-restricted, both the procedure and the office visit may be payable on the same date of service.
42. We do billing for a CRNA and have trouble with procedure code 62279. We were advised to use a modifier for certain diagnoses and not to use a modifier for others. We aren't sure when to use a modifier and when not to. Also, some of the diagnosis codes are restricted, and we don't know when to use certain diagnosis codes and when not to.
Section 10 of the Physician Provider Manual and the 1998 Professional Services Training packet are very specific regarding the billing of anesthesia and when to use modifiers and certain maternity-related diagnoses. You may request a field analyst visit to provide training on this area of Medicaid policy.
43. If a physician is on vacation and has another physician covering for him, how should services performed during that period be billed?
If this constitutes an informal reciprocal arrangement not to exceed 14 days, then the services should be billed by the vacationing physician using his Medicaid provider number. Claims for such services should have the -Q5 modifier appended to all procedure codes billed.
44. If a group practice has several physicians enrolled, and the physician who normally treats a particular patient is on vacation, how should we bill for services when another physician in the practice treats that patient?
These services should be billed under the Medicaid provider number of the physician who actually provided the services to the patient.
45. If a recipient wants contact lenses and glasses, can he pay for the contact lenses?
If medical necessity is met for the glasses and not for the contact lenses, Medicaid would pay only for the glasses. The contact lenses would not be a Medicaid covered service, and the recipient would be responsible for the contact lenses if he insists on having them.
46. If a recipient has exceeded his 12 visits per state fiscal year, can we be paid for any additional visits?
The 158-A process, detailed in Section 7 of the Physician provider manual, addresses this issue. The 158-A form may be submitted to the Unisys Prior Authorization Unit to request an extension of visits in cases of emergencies (e.g., trauma; life-threatening conditions; and life-sustaining treatments, e.g., chemotherapy for malignant diseases or radiation therapy). If the extension is approved, the claim for the approved services must be submitted hardcopy with a copy of the approved extension form attached. Visits exceeding the 12 per state fiscal year that are not approved for extension are billable to the patient, as they exceed established service limits.
47. Will Medicaid pay for supplies used in the office for services performed in the office?
Medicaid does not reimburse separately for supplies used in the performance of office visits or routine office services.
48. Is it acceptable for a practice to refuse to take any new Medicaid patients while continuing to see established Medicaid patients?
Yes, providers may limit the Medicaid portion of their total patient caseload.
49. Will Medicaid pay for a physician to see a patient in a skilled nursing unit?
Medicaid will pay for this service only if the claim is a crossover claim from Medicare (the recipient has Medicare and Medicaid).
50. We are having problems verifying eligibility because of discrepancies between the date of birth given by the patient and the date of birth shown on the MEVS files. We don't usually obtain the social security number of the patient.
Incorrect dates of birth must be corrected at the parish office level. This should be initiated by the recipient. MEVS will allow verification of eligibility using a wide variety of combinations of information, and you may want to start obtaining social security numbers to assist with that process.
51. What can we do if our claims are not crossing over to Medicaid from Medicare?
Please contact our Provider Relations Telephone Inquiry Unit and let us check your Medicare/Medicaid cross-reference file. If your Medicare provider number is not cross-referenced to your Medicaid provider number, then claims won't cross over properly. This is corrected through Provider Enrollment. If only certain recipients' claims are not crossing over, ask us to check the Medicare numbers of those recipients. If the recipient's Medicare number is not the same on our files as the Medicare beneficiary number you are filing to Medicare, the claims will not cross over. In that case, the recipient should have this corrected at the parish office, or you could submit proof of the correct beneficiary Medicare number to the Provider Relations Correspondence Unit with a cover letter requesting that the recipient's file be updated.
52. If a patient comes to us for accident-related services, may we choose not to accept that recipient as a Medicaid patient?
Providers may choose not to accept Medicaid in this instance. However, providers may not accept Medicaid payment for accident-related services and then later void such claims to pursue payment from an outside source, such as a legal settlement.
53. If one physician is performing the professional component of a service and another is performing the technical component, how can both be paid?
Medicaid does not pay technical component only for straight Medicaid claims. For such claims, Medicaid will either pay the full service or the professional component only. If one physician bills for full service, he may use part of his fee to reimburse the physician who performs the professional component only.
54. Which procedure codes are no longer on the global surgery period list?
The current global surgery period list is available by calling our Provider Relations Telephone Inquiry Unit. This list shows all procedure codes currently subject to global surgery period restrictions.
55. Can a physician be paid even if the hospital does not obtain pre-certification?
Physicians can obtain payment for their hospital visits if the hospital fails to request pre-certification or if the hospital's pre-certification request (initial request or extension request) is denied due to timely submittal, provided the requirement of medically necessity is met. The physician should submit his claims, along with the admit and discharge summary, with a cover letter to Provider Relations Correspondence Unit requesting a pre-certification override. The claims will then be reviewed for medical necessity and special handled for processing. Please note that such claims are subject to all normal claims edits, and claims may be denied for reasons other than pre-certification if the claims contain other errors.
56. We are receiving CLIA denials. What can we do?
If you are receiving denials that state you do not have a CLIA certificate on file, fax a copy of your CLIA certificate to the Provider Enrollment Unit with a request to add your CLIA number to your file. If you are receiving denials that state you are not CLIA certified for the procedures you are performing, call Provider Relations Telephone Inquiry Unit to check and see what certification type is on file for your provider number. If the certification type on file is different from what your certificate indicates, you would need to have Provider Enrollment correct your certification type on file by submitting to them a copy of the certificate. If the procedure code you are billing is not one that your CLIA certification allows you to bill, Medicaid will not reimburse you for the procedure.
57. How can I find out which procedure codes can be billed with each CLIA certification type?
Pages 16-17 of the 1999 Professional Services Training packet discuss CLIA certification and include a list of billable procedure codes.
58. We are receiving denials on our visits to patients in SNF units indicating that the recipient is out of visits. Can we be paid for these?
Physician visits to patients in SNF units are payable only for crossover claims. Unless the patient is a QMB (qualified Medicare beneficiary), he is subject to the same physician visit limitation as other recipients age 21 and older. Providers may request an extension of visits in those cases, using the 158-A process discussed in Q26 above. If the extension is not approved, the patient is responsible for the charge.
59. Is the rotavirus vaccine still payable?
The rotavirus vaccine was made non-payable effective October 19, 1999 due to manufacturer's recall.
60. How can we tell when a patient comes in that he is a Lock-in patient?
The REVS and MEVS verification systems both indicate that the recipient is a Lock-in recipient, and they indicate the Lock-in physician's name and phone number. Remember that this is not the same as CommunityCARE. The Lock-in program is discussed in the 2000 Basic Medicaid Training packet.
61. Why would a claim deny for error code 275 ("recipient is Medicare eligible") if Medicare paid on the claim?
Several things could cause this denial-submitting the claim hardcopy without the Medicare EOB attached is the most common reason. Providers may contact the Provider Relations Telephone Inquiry Unit for assistance with specific claim denials.
62. In some paperwork I received, it states that CPT codes 98940, 98941, and 98942 are shown as payable, but in the chiropractic portion of the manual, it states to bill 97260 and 97261 only. Can we bill the 98940-98942 codes? Also, can we bill initial office visits with CPT codes 99212-99215? We are a chiropractic office.
The chiropractic section of the manual refers primarily to the payment of claims for recipients who have only Medicaid. CPT codes 98940-42 are payable for Medicare/Medicaid recipients but not for just Medicaid recipients. If the recipient is covered only by Medicaid, chiropractor
should bill 97260 and 97261 for manipulations. If recipient is Medicare/Medicaid, chiropractors should bill 98940-42 for manipulations. You cannot bill office visits for persons having only Medicaid.
63. We are a chiropractic office, and chiropractic services are exempt from the CommunityCARE referral requirement. Why are we getting denials stating a referral is necessary?
The EPSDT medical screening provider referral is required for ALL chiropractic services for children from BIRTH through 20 years of age effective with date of service 3/1/2000.
64. Can we obtain a list of procedure codes that Medicaid does not pay for?
We do not have a list of codes for which Medicaid does not reimburse. Providers may contact our Provider Relations Telephone Inquiry Unit staff to determine if specific procedure codes are payable. A general rule of thumb is that if the code is not listed on the Professional Services Fee Schedule it is not payable.
65. Why are some of my claims being paid automatically and some are not? Why are they not all being paid if they are all filed electronically?
Without the specifics of the situation, it is difficult to answer that question accurately. However, there are several reasons why electronic claims may deny. Claims that require attachments will always be denied if filed electronically, because we are looking for an attachment to a hardcopy claim. Some instances of this are claims that require proof of timely filing, claims that require an insurance EOB, claims that require documentation for medical review, claims with approved extensions of visits, and claims that require consent forms.
66. Once an adjustment claim is processed, how long does it take for additional payment to be issued?
Hardcopy adjustment/void claims (Unisys 213 forms) are normally processed within 30 days of being received at Unisys. If any additional payment is due as a result of the adjustment, that amount will be included in your payable amount on the remittance advice on which the adjustment appears.
67. If we are voiding a procedure by sending in the void form, can we attach a refund check to the void form, or should we wait until the money is recouped from an RA?
Please do not submit an adjustment/void form (Unisys 213) along with a check. When a void is processed and appears on a remittance advice (RA), the amount payable on that RA will be adjusted to show any amount recouped by Medicaid. If a check and a void form are submitted, in effect the overpayment will be taken back twice. In addition, processing of refund checks is done at DHH and may take several weeks to be completed.
68. Venipuncture is not covered by Medicaid for physicians. Can we bill a minimal office visit code of 99211 for specimen collection?
Yes--the 1998 Professional Services Training packet contains the following statement: "However, if a recipient is seen in a physician's office for specimen collection, a low level office visit code of 99211 may be billed for the visit."
69. How many pairs of glasses are payable by Medicaid per year? Does the three pairs include component parts or just complete pairs?
Medicaid will pay for three pairs of glasses per calendar year without review. Additional pairs may be payable if justified. Please see documented policy in the 1998 Professional Services Training packet. Component parts are not included in the three per year limit unless they are authorized under procedure code X0089. The procedure codes included in the three per year are X6370, X6371, X6372, and X0089.
70. If a patient comes into the office for prenatal services and says she has applied for Medicaid, is she obligated to pay for those services since there is no proof that the application will be approved? What if prenatal lab work is needed and the recipient says she does not have the money for the charges?
This issue is discussed on p. 24 of the 2000 Basic Medicaid Training packet. Providers are not required to accept the recipient's Medicaid card retroactively-that is a matter of choice. Each provider's normal office policy would apply regarding a recipient's ability to pay for services when no Medicaid coverage is in effect.
71. What is the difference, if any, between a pre-certification number and a prior authorization number? When billing for hospital visits, do I need to include the pre-certification or prior authorization number on the HCFA-1500 claim form? This information is usually not available to us.
The pre-certification number is issued once pre-certification approval is requested by a hospital for an hospital stay. The Pre-certification Unit determines medical necessity of the stay based on established criteria. A prior authorization number is assigned when a provider requests authorization of procedures or items requiring prior approval before payment can be made. For physicians, prior authorization is not generally required. However, the 1998 Professional Services Training packet lists some procedures which do require prior authorizations for physicians and other professional providers. It is not necessary for physicians to enter a pre-certification number on claims for hospital visits. The claims processing system "looks" for hospital stays matching the dates of service on hospital visit claims.
72. Does Medicaid cover Epogen injections for ESRD patients with HH levels below the required levels? Would this be covered as an outpatient hospital procedure? Would this be covered in the office?
Normally Epogen is covered when provided by an enrolled Medicaid hemodialysis provider rather than in an outpatient hospital setting. If the procedure code for the Epogen injection is not on the list of payable injection codes on p. 35A - 35B of the 2000 Professional Services Training packet, it would not be an injection covered if administered in the office.
73. Can we obtain a list of mental health clinics for referrals of Medicaid recipients?
Although Unisys does not provide such a list, providers (and recipients) may obtain the names of participating Medicaid providers in order to refer patients by contacting the Disability Information Access Line at (800) 922-3425.
74. Is there an updated procedure codes for billing inpatient psychiatric care for an individual psychiatrist?
Psychiatric services as described in the �908� section of codes in CPT are payable for cross-over claims only. Medical care rendered by psychiatrists may be billed under the appropriate office, hospital, or consult procedure code.
75. If a patient has Medicaid and lives in a group home or nursing home and has a diagnosis of mental retardation, will Medicaid pay for preventive testing such as hepatitis ABC (80059) screen, PRP and PPD for TB? Also, what if Medicare is involved and denies claims for medical necessity?
Any time Medicare denies services as "not medically necessary," such services are not payable by Medicaid. The only preventive service we pay for in Physician�s Program for recipients 21 and older is screening mammograms for women. This service has some restriction. If the person is 21 or older and living in a group or nursing home, preventive services should not be billed even if diagnosis is mental retardation and code is payable in file.
76. A patient was seen in our (physician) office and had blood work, an EKG, and IV fluids, and was then admitted to the hospital. I know we can only bill for the hospital admission and not the office visit, but what about the other services performed in the office? Can we bill for these services?
Laboratory services and other payable services performed during the course of the office visit can be billed as usual. In-office administration of IV fluids is not covered by Louisiana Medicaid.
77. How can we be reimbursed for Rocephin shots that help to keep children out of the hospital?
Rocephin and all other antibiotics for children to age 21 are payable through the Physicians Program. Provider could bill code 90782 or the doctor may have to give the recipient a prescription.
78. Is there a time limit for obtaining a referral from the PCP?
There is no stipulated time limit on obtaining a referral from a PCP; however, it is prudent to obtain the referral prior to providing the service, if possible, or as soon as possible afterward.
79. Is it acceptable for one PCP to give a referral to another PCP because the recipient is changing PCPs and the paperwork to do so is still being processed?
Administrative referrals of this nature are acceptable in such instances.
80. If the referral provider has to send his patient for other services, does his referral cover those additional services?
The referral issued by the PCP covers the services of the specialist or hospital, depending upon to whom the referral is issued. If that specialist or hospital has to send the patient for additional services related to that referral, a copy of the referral form should be shared with the provider(s) of those additional services.
81. As a PCP who has given a referral to the hospital for inpatient services, must we give referrals to all providers who provide services to that patient while in the hospital?
It is the hospital's responsibility to share the referral with all other providers who render services to a recipient who is an inpatient in the hospital.
82. I have a PCP referral for my services, but I also need to send the patient for outpatient hospital work in connection with my services. How does the hospital obtain its referral?
Since you are sending the patient for services in conjunction with the reason the patient was referred to you, you should share your referral with the hospital.
83. If a hospital does not precert a case, how can the physician's office get payment for services rendered?
Please review the following cases:
1. If the hospital did not precertify the stay, the physician can send a cover letter, the claim, and the admit and discharge summary to the PR Correspondence Unit. The Correspondence Unit, after reviewing the documentation, will forward the documents to the Pre-Cert Department for approval consideration.
2. If the hospital did not request an extension in a timely manner, the physician can then send the same information as in case #1.
3. If a pre-cert is denied for any reason other than timely submission, such as the stay did not meet established criteria, then no provider can be reimbursed for services.
84. When an adult patient exceeds the 12-outpatient visit limit and it is a life threatening situation, do you need to obtain the visit extension authorization before you render the service?
When outpatient visits exceed the established service limit, visit "extensions will be granted only for emergencies, e.g., trauma; life threatening conditions; and life-sustaining treatments, e.g., chemotherapy for malignant diseases or radiation therapy" (Physician Services manual, p. 7-2).
If you are certain your visit meets the above mentioned criteria, please note that visit extensions are approved retroactively.
Pre-certification Questions
1. If a provider inadvertently forgets to file an extension to a precert, can the provider still be paid?
As long as the patient is still an inpatient, the provider may file for additional days by submitting a request for a new pre-certification number. The provider must submit the PCF01, requesting an extension (although it will be denied for untimely submission). The provider does not need to send documentation with this request. Several hours later, the provider should submit another PCF01 being sure to indicate it as an initial request with no pre-certification number noted and submitting required documentation with that PCF01. The provider should write "Attention Janeen or Sandy" in the upper right-hand corner and include the old pre-certification number on the bottom of the request.
2. If the common working file is submitted on plain paper and not hospital letterhead, will this be rejected if the common working file (CWF) is being submitted for proof of Part A being exhausted?
No. A printout of the CWF is only rejected because it does not clearly indicate that Medicare Part A was exhausted.
3. If recipient has BC/BS, Aetna and Medicaid, should the stay still be pre-certified?
Yes. The only time a stay should not be pre-certified is if the recipient has Medicare Part A.
4. We pre-certify Part A recipients because sometimes all days show not to be exhausted, but later we find out that a hospital had not billed timely and days were truly exhausted. Is that okay?
It is permissible. If you copy the CWF showing Part A days remaining and a copy of the file showing exhausted, Unisys will pre-certify the case. If there is doubt as to Part A days being exhausted pre-certify the case. The Unisys Pre-certification department will return the case if there are Part A days left.
5. Does the hospital contact person on the pre-certification file have to be the same person who signs the form (authorized signature)?
No, it is not necessary that these be the same person.
6. Is Unisys off on Christmas Eve?
It depends on the day of the week on which Christmas occurs. If Christmas is on Saturday, Unisys is closed on the previous Friday. If Christmas is on Sunday, Unisys is closed on the following Monday. If Christmas is on any weekday, Unisys is closed that day only.
7. Is a cover page needed when we fax one page?
It is always a good idea to have a cover sheet when faxing, even if only one page is being faxed.
8. What should be indicated on pages that must be refaxed? Should "refax" be written on them?
No, that is not necessary. The provider must only fax the medical documentation that is required to process the request.
9. For retrospective review, should the patient's entire chart be sent?
Providers should send only the documentation that shows the criteria being met for the length of stay (LOS) being requested for retrospective review.
10. How many hours do we have to get a pre-certification request to Unisys?
For an initial request, providers must submit the request by the end of the next business day following the date of admission.
11. Do we have to precert a patient who has private insurance and Medicaid?
Pre-certification is required even if the patient has private insurance, and the request must be submitted timely.
12. How do we remove a person's name from the authorization list for a hospital?
Providers should send a letter to Sandy's attention indicating the following information:
1. Provider name
2. Provider number
3. Name of person no longer authorized to receive information for your hospital.
This letter should be signed and should include the credentials of the person signing.
13. If a patient is on multiple medications, wouldn't it be more effective to write "see attached" on the PCF01 and refer to the medical sheets rather than list every medication being administered?
The provider only needs to indicate those medications that enable Interqual criteria to be met, and the provider may submit the medication sheet showing those medications.
14. When should you check on a retrospective review?
Providers should call two weeks after sending such a request to ensure that it was received. Since Unisys is allowed three weeks to review these, there may not be a final case status after two weeks.
15. Are we able to get special consideration for late initial requests?
No, only in the case of a late extension may there be any way to pre-certify some of the days.
16. How do I get a precert if my admissions department does not distinguish between Medicare Part A and Medicare Part B?
Pre-certification requests should be submitted as soon as such an error is discovered to allow for the best chance to request timely pre-certification. Ultimately it may be necessary for your staff to develop an internal process for handling these situations.
17. Are there any special considerations to psychiatric facilities if they do not obtain timely initial precert?
No-psychiatric hospitals must adhere to the same guidelines as other hospitals for timely submission.
18. What should a provider do if a patient presents as private pay and then is discovered to be a Medicaid recipient after being received? In this instance, the MEVS record indicated no Medicaid coverage on the date in question.
Pre-cert will be approved if the provider submits a copy of the MEVS printout showing no Medicaid coverage at the time of admission.
19. Do providers need to submit a PCF01 to pre-certify for a vaginal delivery and tubal ligation?
All inpatient stays must be pre-certified unless the admitting hospital is a charity facility or an out-of-state facility.
20. If CWF indicates that a patient has Medicare Parts A & B, Medifax indicates Part B only, and patient is being transferred to our skilled unit, do we pre-certify the case or not?
If there is any question that the recipient has Medicare Part A eligibility, request pre-certification of the stay. However, Medicaid does not issue pre-certification for skilled units within the hospital setting. (Hospital skilled unit services are payable by Medicaid only for crossover claims.)
21. If a patient presents to a psychiatric facility with substance abuse and psychiatric diagnoses, how do we pre-certify the case? In one instance, the patient arrived at our hospital drunk and having bouts of depression, threatening suicide.
The answer will be different for every case. In this instance, it appears that drunkenness would be appropriate as the initial diagnosis. By the time you need to do an extension, you may need to use depression as the diagnosis. According to the DSM-4, the substance abuser may exhibit psychiatric symptoms caused by substance abuse.
22. Should you split bill the claims that have days that are not authorized?
In an instance in which only certain days of a stay are pre-certified, providers should bill only for the days that are pre-certified.
23. Can we pre-certify a well baby if the doctor wants to hold the baby after the mother is discharged?
No--only a sick baby or a healthy baby whose mom is not Medicaid eligible may be pre-certified.
24. Do we have to submit documentation when the recipient was an outpatient and we later admitted him for an inpatient stay?
If the stay is longer than 24 hours, the patient is deemed inpatient and the hospital must pre-certify that stay. If the recipient stays less than 24 hours and is discharged as an outpatient, the stay cannot be pre-certified. The discharge order must indicate the discharge time.
25. What should I do when the doctor indicated an admission and the stay wasn't approved through the pre-certification process?
Providers have the option to request a written reconsideration and/or schedule a doctor phone conference. Page 13 of the 2000 Pre-certification Training packet discusses the reconsideration process.
26. What is the turnaround time for Unisys' response to a written reconsideration request?
The turnaround time on such requests is 24 hours.
27. Our utilization review (UR) nurse is going on vacation, so how should we keep up with submitting pre-certification requests in her absence?
Someone in your office will need to ensure timely submissions of pre-certification requests. You may indicate the name of an additional person authorized to handle pre-certification requests by writing the authorized person's name in on a PCF-01 shortly before the UR nurse leaves for vacation. This will allow Unisys to discuss necessary pre-certification submissions with someone other than the vacationing nurse.
28. What if an initial request for precert is not obtained timely? Is there any provision to allow reconsideration for this untimely initial precert request?
There is no provision for reconsideration of an initial request which has been denied for timely submittal. The only option providers have is to follow the appeal process through the DHH Appeals Bureau.
29. Is there a cut-off time for requests being submitted on Friday?
The cut-off time for Friday submissions is 12 o'clock midnight.
30 What information is needed with a resubmittal?
Because the Unisys Pre-certification department now has imaging of pre-certification requests, all that providers are required to submit is the PCF01 indicating "resubmittal" and the requested information that shows criteria being met for the requested days.
31. Can all pre-certification requests be faxed?
Yes, all pre-certification requests may be faxed.
32. Our pre-certification was approved for 5 days. How much documentation should be sent for an extension?
The required documentation would be that of the last 48 hours of the approved stay.
33. On the PCF-02, can we write "see attached"?
No, providers must actually summarize the documentation being sent to substantiate the request.
34. If, as a UR person, you know the EGD will be denied, should you even worry about requesting pre-certification?
If the EGD was done on the day of admission or the day after and if you are going to bill for the EGD, it must be precerted in order for it to be reimbursed.
35. If a patient comes in on a Monday as an outpatient and he comes in on Tuesday for a legitimate inpatient stay, how do we pre-certify? If we don't pre-certify on Tuesday, is it too late?
If the patient became an inpatient on Tuesday, you have until the end of Wednesday to pre-certify that patient. The admit date shown on the PCF01 will be Monday.
36. We are a long-term facility--what do we do if we pre-certify a patient for one day and he does not come until the next day?
You have 24 hours from the actual admit day to update the admission date. Please note that only long-term facilities can pre-certify stays anticipating the admission date.
37. If a patient is discharged and readmitted on the same day, do we need to get a new precert?
No. If a patient is discharged and readmitted on the same date, this should be precerted as a continuous stay and medical necessity must be determined. The same pre-certification number will be used for the entire stay.
38. We are a long-term facility. If we send a patient out for outpatient procedures, we are responsible for reimbursing the outpatient facility. Is there a time frame when we are not responsible?
If the patient is outpatient for more than one calendar day, you should discharge the patient. The other facility performing the procedure should pre-certify the stay in their facility, and the long-term facility should obtain a new precert beginning the day the patient returns.
39. If a baby is pre-certified and the mother has a condition which extends her stay after the baby no longer meets criteria for pre-certification, should we try to precert an extension for the baby?
You may submit an extension for the baby. However, if the baby does not meet criteria, the extension will not be approved. That the mother is still inpatient is not sufficient reason to extended the baby's pre-certification.
40. According to p. 2 in the 2000 Pre-certification Training packet, the 1993 version of HCIA LOS Criteria is used. Earlier today we were told that effective with date of service 2/7/00, the HCIA LOS was updated using the 1999 version and will be updated annually. Which version of HCIA LOS Criteria is used?
The 1999 version of HCIA LOS Criteria is the one being used by the Unisys Pre-certification department. The latest version will be loaded each February.
41. Let's say a patient comes in and days are originally assigned as initial LOS. It is then determined that a major surgery needs to be performed which would drastically change the days approved for this recipient. Should we send in additional information immediately or wait until it is time to file an extension and send documentation at that time?
Wait until you file your extension request to send updated information documenting the patient's change in days that will be requested.
42. If an update is sent because the admit needs to be backed up a day to cover an observation day, does the original approved number of days increase by one to show the additional day?
No. The original approved days remains the same. The discharge date approved will be moved up one day. An extension of days should be requested accordingly and in a timely manner.
43. When an additional pre-certification number has been obtained because of a denial for timely filing, how would the resulting charges be billed?
Two separate claims should be billed, one for each part of the stay. In addition, each claim form must have the corresponding pre-certification number indicated in form locator 63.
44. How far does the documentation go back when obtaining a new pre-certification number after denial for timely submittal?
The documentation in this case goes back 48 hours.
45. If an outpatient procedure is being performed and the stay becomes inpatient, what would be the admit date?
The date of the outpatient procedure would become the day of admission. The documentation should show medical need of the inpatient admission for what was planned to be an outpatient procedure.
46. Can a hospital get precertification for a stay when the recipient presents a retroactive eligibility card?
Yes. The hospital would need to send appropriate documentation to the attention of Sandy Whitcomb, supervisor of the Precert Department at Unisys.
47. If a patient has both Medicare and Medicaid, is Precertification required?
Precertification is required only if the patient's Medicare Part A is exhausted or when they do not have Medicare Part A.
48. Does the doctor have to put the precert number on his claim?
No. When the claim hits the system, the system looks for an approved precertification for those dates; therefore, it is not necessary for the physician to have the precert number on the claim.
Changes To The Controlled Dangerous Substances License Form
Two new lines have been added to the Louisiana Controlled Dangerous Substance (CDS) License
automated renewal form:
1. A line has been added immediately below the felony attestation for the practitioner to attest to the expiration date of his/her current practitioner's license. Please put your most current board expiration date in this space.
2. Below the space for the two addresses (business and home), a block has been added for the
practitioner to indicate to which address the Louisiana CDS license should be mailed.
REMEMBER! Louisiana Controlled Dangerous Substances licenses and United States Drug Enforcement Administration registrations are "site specific" for the location where controlled substances are utilized. However, the CDS license may be mailed to an alternate address. Although the license is "site-specific" for the location where the controlled substances are to be utilized, the practitioner may prescribe controlled substances anywhere within the state in which he/she is licensed, and may keep small quantities of drugs with him/her for emergencies.
Louisiana Drug Utilization Review (LADUR) Education
Hepatitis C: The Silent Killer
Issues
� Hepatitis C is the most common blood-borne infection in the United States
� The asymptomatic nature of the disease makes it difficult to diagnose.
� Approximately 8,000 to 10,000 deaths each year are attributable to hepatitis C.
� New treatments are available for hepatitis C to prevent the progression of hepatic disease.
W. Greg Leader, Pharm.D.
Head and Associate Professor
Department of Clinical and Administrative Sciences
College of Pharmacy
The University of Louisiana at Monroe
INTRODUCTION
Chronic viral hepatitis is the primary cause of chronic hepatic disease (including cirrhosis and hepatic cellular carcinoma) in the world, and infection with hepatitis C virus is the principle form of chronic viral hepatitis in the United States. Hepatitis C, formerly known as non-A/non-B hepatitis, is the most common blood-borne infection in the United States. Although only approximately 36,000 cases occur each year, an estimated 3.9 million Americans have been infected and approximately 68% of those have chronic hepatitis C infection.
CLINICAL COURSE
Acute Hepatitis C
The onset of hepatitis C is usually asymptomatic and may often go unrecognized. Some patients may develop a flu-like syndrome or non-specific complaints such as loss of appetite, malaise, abdominal pain or fatigue. Although virtually all patients will develop hepatocellular injury as indicated by increases in serum alanine aminotransferase (ALT), less than 30% of patients develop jaundice with acute infection. Because hepatitis C is a quasispecies (individual isolates are closely related populations of viral genomes), it has the unique ability to escape the body's immunologic surveillance system; thus, causing chronic infection. Because of this, hepatitis C is self-limited in less than 15% of the cases.
Chronic Hepatitis C
Approximately 85% of the patients acutely infected with hepatitis C fail to clear the virus within six months of being infected and develop chronic hepatitis. Progression of the disease is often insidious with most patients remaining asymptomatic for more than 20 years. Because of the indolent and asymptomatic nature of the disease state, diagnosis is usually serendipitous, occurring as a result of testing done when donating blood or for other procedures (surgery, life insurance policy, etc.), or as a result of symptoms occurring from acute liver failure (ascites, variceal bleeds, hepatic encephalopathy).
The rate of progression of hepatitis C is highly variable, and changes in ALT concentrations do not correspond well with disease severity, which is usually classified using histological testing. Liver biopsy results may be quite varied ranging from a mild degree of hepatitis to cirrhosis and end-stage liver disease. Complications of chronic hepatitis C include cirrhosis, liver failure, and liver cancer. Hepatitis C is the most common reason for liver transplants in the United States, and approximately 20% of patients with chronic infections develop cirrhosis within 10-20 years of being infected. Chronic hepatitis C is also the most common cause of primary hepatic cancer with patients with cirrhosis, men, alcoholics, people over the age of 40, and patients infected for 20-40 years most likely to develop this cancer.
In addition to these manifestations, patients with chronic hepatitis C may occasionally present with extrahepatic manifestations usually of immunologic origin. These manifestations may include arthritis, keratoconjuctivis sicca, lichen planus, glomerulonephritis, and cryoglobulinemia.
Five-year survival rates for uncomplicated chronic hepatitis C infection are greater than 90%; however, the five-year survival rate among chronically infected patients developing decompensated cirrhosis is approximately 50%. These numbers translate into approximately 8,000 to 10,000 deaths each year attributable to hepatitis C. The majority of patients currently infected with hepatitis C are 30-49 years of age, and thus, the number of deaths from hepatitis C associated liver disease are expected to increase over the next two decades.
RISK FACTORS
The hepatitis C virus is transferred primarily through contact with blood and blood products. Most commonly, the virus is transmitted through large or repeated percutaneous exposure to contaminated blood. In the early 90s, routine testing of donated blood for hepatitis C antibody has virtually eliminated the greatest risk of transmission; thus, the largest current risk for developing hepatitis C is injected-drug use, which accounts for approximately 60% of new cases. Currently, the risk for transfusion-associated hepatitis C is 0.001% (1 in 100,00 per unit transfused). Sexual transmission among monogamous partners is rare with only 5% of spouses and monogamous partners being infected. Other studies have estimated the risk of infection from a hepatitis C infected partner to be as low as 1.5% in a long-term monogamous relationship. Transmission of the virus from an infected mother to a fetus occurs rarely with approximately 5% of infants infected. Fetal risk of infection increases with the amount of virus in the mother's blood and when the mother is co-infected with the human immunodeficiency virus. The transmission of the virus through breast milk has not been documented; therefore, breast-feeding is not contraindicated in hepatitis C positive mothers.
As many as 10% of new infections have no known risk factor associated with them, but may be caused by exposure to the virus from cuts, wounds, or medical procedures. Finally, recent data indicates an association between tattooing and hepatitis C infection; however, further epidemiological testing is needed to confirm this association. Identifying patients at risk for hepatitis C infection requires an understanding of what behaviors or activities increase the risk of infection. Table I lists at risk patient populations.
SCREENING AND DIAGNOSIS
Patients suspected of being infected with the hepatitis C virus should be tested for the presence of the hepatitis C antibody (anti-HCV) in the serum (Table 2). This test is performed using an enzyme immunoassay and has a high specificity and sensitivity detecting the anti-HCV in 97% of infected patients. False negatives occur rarely, and usually occur between exposure and seroconversion, in patients infected with the human immunodeficiency virus, patients receiving chronic dialysis, and immunosupressed patients (e.g., transplant patients). False positives are less common and usually occur in the testing of healthy blood donors. In patients where a false positive is suspected (no risk factors, normal liver enzyme tests), a confirming test such as the recombinant immunoblot assay (RIBA) should be used to confirm or deny infection. Patients who test positive for the anti HCV should have hepatitis C viral ribonucleic acid (HCV RNA) measured by polymerase chain reaction (PCR), particularly those patients with normal liver enzyme tests. The presence of HCV RNA indicates an active infection, and in immunocompromised individuals, identifying HCV RNA using PCR may be the only way to obtain a positive diagnosis. Unlike the measurement of viral loads in patients with human immunodeficiency virus, hepatitis C viral loads do not appear to correlate well with disease severity or prognosis.
Once a diagnosis of hepatitis C has been made, the severity of the disease should be assessed. Liver enzyme tests do not correlate well with chronic disease severity. Serum albumin, bilirubin and prothrombin time do appear to correlate with disease severity, but are usually not elevated until there is severe liver damage. Therefore, in patients with chronic hepatitis C, a liver biopsy to determine disease severity should be considered. In patients abstaining from alcohol and a known duration of infection less than 10 years, a biopsy may lend little to evaluation; however, in those patients with a history of heavy alcohol use or duration of infection greater than 10 years, a biopsy is recommended. In all patients, a liver biopsy may be helpful in guiding therapy.
Patients testing positive for anti HCV should also be tested for concomitant diseases such as hepatitis B and HIV that share similar transmission profiles. In addition, immunity to hepatitis A and B should be assessed, and if it does not exist, the patient should be immunized against hepatitis A and B. The patient's iron stores should also be assessed, as iron overload has been associated with an increased risk of fibrosis. Finally, hepatitis C genotyping should be considered. The most common genotypes in the United States are 1a and 1b; unfortunately, these genotypes are also less likely to respond to alpha-interferon therapy.
TREATMENT
The primary goal of therapy is the eradication of the virus and the prevention of liver disease progression. Rapid referral of acute cases is important, as early treatment with alpha interferon appears to decrease the risk of chronic infection. Patients should be counseled to abstain from alcohol use, and potentially hepatotoxic medications should be avoided.
Currently, two different therapies have been approved in the United States for the treatment of hepatitis C infection: alpha interferon monotherapy and combination therapy with alpha interferon and ribavirin. Several forms of alpha interferon are available including alfa-2a, alfa-2b, and alfacon-1 (consensus interferon). Although initial treatment recommendations included monotherapy with interferon alpha, the most recent NIH guidelines published in 1999 recommend combination therapy with interferon alpha 2b and ribavirin. Current recommendations state that therapy should be initiated with 3 million units of interferon alpha given via subcutaneous injection three times a week and oral ribavirin 1000 mg (patients < 75kg) - 1,200mg (patients > 75kg) daily in two divided doses. After 24 weeks of therapy, aminotransferase levels and hepatitis C viral RNA should be assessed. In patients with genotypes 2 and 3, therapy should be terminated. In patients with genotype 1, therapy should be discontinued in patients who are still positive for hepatitis C viral RNA or continued for a total of 48 weeks in patients negative for hepatitis viral RNA. Factors that may predict eradication with antiviral therapy are listed in table 3. In addition to these factors, patients who have not had viral eradication by 24 weeks are unlikely to respond to further therapy. Approximately 50% of patients treated with interferon alpha alone relapse, and combination therapy for a minimum of 48 weeks is the standard of care for treating patients relapsing after monotherapy.
One of the primary concerns with interferon alpha therapy is lack of compliance due to adverse effects. Although major adverse effects can occur, minor adverse effects are more common and can be bothersome. Six to nine out of ten patients treated with interferon alpha will experience flu-like symptoms (malaise, fever, chills, myalgia, tachycardia, and headache) after the first few doses. These side effects can be diminished through the use of acetaminophen or non-steroidal anti-inflammatory agents. Later adverse effects include anorexia, fatigue, malaise, reversible alopecia, skin rash, and weight loss. Approximately 25% of the population will develop neuropsychiatric adverse effects including irritability, insomnia and mood and cognitive changes. These adverse effects can be effectively managed with antidepressants. Neutropenia, mild anemia, thrombocytopenia and irreversible thyroid dysfunction may also occur.
The primary problem associated with ribavirin therapy is the development a reversible hemolytic anemia; however, less severe adverse effects such as fatigue and irritability, itching, skin rashes, nasal symptoms (stuffiness, sinusitis), and cough may also occur. Both interferon and ribavirin are teratogenic and should be avoided in pregnant women. Women of child bearing age and male partners of women of child bearing age should be counseled concerning theses effects. Women of child bearing age receiving therapy or having sexual intercourse with a male partner receiving therapy with these agents should be strongly counseled to use two reliable forms of birth control during therapy and for up to six months following discontinuation of therapy. Although combination therapy is more effective than monotherapy, it is also less well tolerated.
The chemical combination of interferon alpha with polyethylene glycol (pegylated interferon alpha) leads to an effective treatment with a long duration of action. This modification allows for once weekly dosing with improved efficacy.
MONITORING OF THERAPY
In addition to confirming the diagnosis through liver biopsy and measurement of serum HCV RNA by PCR, patients should be tested for hepatitis C genotype (or serotype) to help determine the duration of therapy. Prior to instituting therapy, complete blood counts (including hemoglobin, white blood cell count and platelet count) and aminotransferases should be measured to establish a baseline, and patients should be counseled concerning the benefits and risks of therapy with particular attention to potential adverse events. In addition, a thyroid stimulating hormone level and pregnancy test should be evaluated at baseline. The pregnancy test and the complete blood count should be repeated 1, 2 and 4 weeks after the initiation of therapy and then monthly thereafter. Aminotransferase levels should be repeated 1, 2 and 4 weeks after therapy is initiated, every 4-8 weeks thereafter while therapy continues and every two months for 6 months after therapy is discontinued. Hepatitis C viral RNA should be measured by PCR at week 24 and the patient evaluated for continued therapy. Viral RNA should be evaluated at the end of therapy to determine end-of-treatment response and again six months after therapy is discontinued. If the patient has a negative test for hepatitis C viral RNA six months after therapy, the chance for long-term cure is excellent.
CONCLUSION
Chronic hepatitis C infects a large number of people in the United States. Because many patients are asymptomatic, chronic infection can lead to serious sequelae including liver failure, cirrhosis, and hepatic carcinoma. Hepatitis C is the leading indication for liver transplantation and the hepatitis C related mortality rate will probably increase over the next couple of decades. Avoiding high-risk behaviors associated with infection is the most important mechanism for preventing infection; however, combination therapy with interferon and ribavirin provide an effective means for treating chronically infected patients. Patient counseling and monitoring is paramount to the success of therapy.
REFERENCES
1. Hoofnagle JH, Di Bisceglie, AM. The treatment of chronic viral hepatitis. N Eng J Med.
1997, 336:347-356.
2. Alter MJ, Kruszon-Moran D, Nainan OV, et al. The prevalence of hepatitis C virus infection
in the United States, 1988-1994. N Eng J Med. 1999; 341-556-562.
3. Gross JB. Clinician's Guide to hepatitis C. May Clin Proc. 1998;73: 355-361
4. Centers for Disease Control. Recommendations for prevention and control of hepatitis C
virus (HCV) infection and HCV-related chronic disease. MMWR. 1998; 47:1-39
5. Management of hepatitis C. NIH Consensus Statement. 1997; 15(3):1-41.
6. Chronic Hepatitis C: Current Disease Management. NIH Publication No. 99-4230. 1999
(updated November 2000):1-27.