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Louisiana Medicaid

Louisiana Medicaid

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Louisiana Medicaid

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  1. UNISYS Louisiana Medicaid DHH – Bureau of Primary CarePractice Management Technical Assistance Workshop August 13th , 2008

  2. Professional Services for Physicians Nurse Practitioners RNs School Based Health Centers

  3. Billing for Professional Services • Individual Physicians Practicing Independently or within a Group • Fee Schedule with procedure codes @ www.lamedicaid.com – link Fee Schedules • Nurse Practitioners • Must be supervised by a Physician • Provide services only within scope of license • Paid 80% of physicians’ fees (100% for immunizations) • Registered Nurses • Can only provide KidMed Screenings/Immunizations • Must be supervised by a Physician • School Based Health Centers • Can only perform services for which they have staff and that they are enrolled to provide

  4. KIDMED SCREENINGS • In order to obtain KIDMED linkage, providers MUST CALL ACS to verify the screening provider on record for the date that the screening is being rendered • RS-0-07 reports are now online and are no longer mailed to providers • Only Medical, Vision, and Hearing Screenings are billed on KM-3 (hardcopy) or 837P with the K-3 (KIDMED) segment (electronically) • Immunizations, Laboratory Tests, Interperiodic Screenings, Consultations, and Low Level Visits are billed on the CMS-1500 (hardcopy) or on the 837P (electronically)

  5. KIDMED Screening Policy Medical Screening • Must perform all 5 components • Providers must use the age appropriate code in order to avoid claim denial Providers should use the TD modifier to report a screening that was performed by a nurse.

  6. KIDMED Screening Policy VISION SCREENING • Subjective Vision Screening • Included in medical component • Objective Vision Screening • Begins at age 4 • Bill with procedure code 99173 with the EP modifier HEARING SCREENING • Subjective Hearing Screening • Included in medical component • Objective Hearing Screening • Begins at age 4 • Bill with procedure code 92551

  7. 2 yr old receiving a medical screening by a physician – Immunizations current. Suspected medical condition/referral info inc

  8. 7 yr old receiving screenings by a nurse – Immunizations are not current. Suspected medical condition and referral info included.

  9. Interperiodic Screening by a Physician

  10. Four Immunizations Given

  11. Billing for Procedure Code 99211 • Physicians may write prescriptions for injections covered under the Pharmacy program and have the prescription filled by a Medicaid enrolled pharmacy. • The recipient may then bring the dispensed medication to the physician’s office and a low-level office visit (99211) could be billed as long as a higher level visit had not been billed on that particular date. • If the injection is given during a more complex visit, that appropriate code for the visit should be billed and there would not be a separate charge for administering the injection. NOTE: This policy excludes RHC’s, FQHC’s, and KidMed Clinics.

  12. Common Billing Errors • General Claim Form Completion Codes • 003 – Recipient # invalid or less than 13 digits • 028 – Invalid or missing CPT code • Recipient Eligibility Error Codes • 215/216/222/223 – Recipient not on file/not eligible on one or more DOS • 217 – Name/# on claim does not match file • CommunityCARE Error Codes • 106 – Billing provider is not PCP/Services not authorized by PCP • Timely Filing Error Codes • 272/371 – Claim exceeds 1 year filing limit/attachment requires review • TPL Error Codes • 273 – TPL carrier code missing • 290 – No EOB from primary carrier attached • Miscellaneous Error Codes • 299/232 - Procedure not covered by Medicaid/type of service not covered

  13. Timely Filing Guidelines • Initial Filing Limits • Dates of Service Past Initial Filing Limit • Two-Year Filing Limit • KidMed Filing Limits

  14. Appeals Process • Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys • Appeals may be filed when all efforts to get the claim paid have been exhausted • Requests must be submitted in writing to • DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La. 70821-4182

  15. CommunityCARE • Program Description • Exempt Recipients • Primary Care Physician (PCP) • Non-PCP Providers • Exempt Services

  16. CommunityCARE • Provider Assistance: • ACS: • Linkages/Monitoring/Certification – 800-259-4444 • Referral Assistance – 877-455-9955 • Unisys Provider Relations: • Billing/Claims – 800-473-2783 or 225-924-5040 • Recipient Assistance: • ACS - 800-259-4444

  17. If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP Can either treat the recipient and not bill Medicaid Offer to see the recipient as a private pay patient (enrollee pays out of pocket) Request an extension using the 158-A form Issue a referral to a physician who will treat the recipient Outpatient Visit Limits

  18. Mental Health Services • Effective 10/01/07, LA Medicaid reimburses professional service providers for select procedure codes specific to psychiatric services • Providers must use procedure codes 90801-90802, 90804-90815, 96101 • Services are counted toward the outpatient visit limits allowed per calendar year • Psychiatrists • Independently practicing or groups • Services covered are those provided by any physician under the scope of the psychiatric license • Reimbursement is based on fee-for-service

  19. Federally Qualified Health Centers And Rural Health Clinics

  20. Billing for Services in an FQHC/RHC Setting • Must bill with encounter code T1015 for both Professional Services and KidMed Screenings • Attending provider information also reported on claim form as well as Group provider info • Clinic is paid based on the Encounter Rate set by DHH for that particular provider

  21. FQHC/RHC Physician Encounter

  22. KIDMED Periodic Screening by a Nurse

  23. Common Billing Errors • FQHC/RHC Error Codes • 092 – Invalid procedure modifie • 136 – No eligible service paid, encounter denied • 210 – Provider/Procedure conflict • 517 – KidMed format required • 518 – KidMed information missing • 715 – Duplicate edit – only one encounter paid per day

  24. Timely Filing Guidelines • Initial Filing Limits • Dates of Service Past Initial Filing Limit • Two-Year Filing Limit • KidMed Filing Limits

  25. Appeals Process • Denied claims ARE NOT considered appeals and should be corrected and re-filed to Unisys • Appeals may be filed when all efforts to get the claim paid have been exhausted • Requests must be submitted in writing to • DHH Bureau of Appeals P.O. Box 4183 Baton Rouge, La. 70821-4182

  26. CommunityCARE • Program Description • Exempt Recipients • Primary Care Physician (PCP) • Non-PCP Providers • Exempt Services

  27. CommunityCARE • Provider Assistance: • ACS: • Linkages/Monitoring/Certification – 800-259-4444 • Referral Assistance – 877-455-9955 • Unisys Provider Relations: • Billing/Claims – 800-473-2783 or 225-924-5040 • Recipient Assistance: • ACS - 800-259-4444

  28. If a CommunityCare recipient has used up all visits and needs non-emergent care, the PCP Can either treat the recipient and not bill Medicaid Offer to see the recipient as a private pay patient (enrollee pays out of pocket) Request an extension using the 158-A form Issue a referral to a physician who will treat the recipient Outpatient Visit Limits

  29. Mental Health Services • Billing for Psychiatrist Services • PCP Referral NOT required for services rendered by a Psychiatrist • MUST enter psychiatrist’s provider number and/or NPI as attending • Billing for Social Workers/Psychologists • Services DO require a PCP referral • Must enter the RHC/FQHC group number and/or NPI as the attending and billing provider • Refer to Professional Fee Schedule for procedure codes • Services are paid based on an Encounter Rate established by DHH • Services are counted toward the outpatient visit limits allowed per calendar year

  30. Provider Assistance • Provider Relations Telephone Inquiry Unit: 800-473-2783 or 225-924-5040 • Correspondence Unit: Unisys-Provider Relations P.O. Box 91024 Baton Rouge, LA. 70821 • Field Analyst • Phone Numbers for Provider Assistance

  31. Thank You For Attending this 2008 Provider Workshop.