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Emergency Medical Services for Aliens EMSA January 2010 Presented by Erminia Reynaga Carlos Trujillo Provider Field

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Emergency Medical Services for Aliens EMSA January 2010 Presented by Erminia Reynaga Carlos Trujillo Provider Field

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    1. Emergency Medical Services for Aliens (EMSA) January 2010 Presented by Erminia Reynaga & Carlos Trujillo Provider Field Representatives

    2. January 2010 2 Call 505-246-0710 or 800-299-7304 - to directly reach all provider help desks including Provider Relations, Provider Enrollment, the HIPAA/EMC help desk and TPL. ACS Helpdesks

    3. January 2010 3 Provider Field Representative: Carlos Trujillo (505) 246-9988 Ext. 221; (800) 282-4477 Ext 221 Email address- Carlos.Trujillo@acs-inc.com Erminia Reynaga-(505) 246-9988 Ext. 104; (800) 282-4477 Ext 104 Email address- Erminia.Reynaga@acs-inc.com ACS Field Representatives

    4. January 2010 4 IMPORTANT UPDATE! Electronic Funds Transfers (EFT) Electornic Funds Transfers (EFT) is part of the ongoing effort by MAD and ACS to transform Medicaid program capabilities into efficient electronic processes. To implement EFT, we will build on the capabilities of ACS NM Medicaid web portal that providers currently use for other electronic activities. We recognize that there is a need for increased security regarding EFT so access to this web function will be limited to the Master Administrator for your organizations account on the web portal. Currently providers are able to sign up for EFT for electronic payments.

    5. January 2010 5 All information will be verified and validated against the information ACS already has for the provider. While registering for EFT using the web portal, the Master Administrator will be asked to supply an e-mail address for receipt of notifications. This e-mail address will also provide a security purpose for EFT because a provider will be notified whenever a change is made to the banking information associated with EFT. IMPORTANT UPDATE! Electronic Funds Transfers (EFT)

    6. January 2010 6 Basic Policies The New Mexico Medicaid program is required to pay for necessary emergency services furnished to individuals who are undocumented aliens, reside in New Mexico and meet the requirements for Medicaid eligibility.

    7. January 2010 7 The Policy Manual for Emergency Services for Undocumented Aliens can be found at the following State website: http://www.hsd.state.nm.us/mad/pdf_files/provmanl/prov832510.pdf The Billing Instructions for Emergency Services for Undocumented Aliens can be found at the following State website: http://www.hsd.state.nm.us/mad/pdf_files/BillingInstructions/832510.pdf Basic Policies

    8. January 2010 8 Eligible individuals Whos covered? Individuals who are undocumented, and non-immigrant aliens and who meet all the eligibility criteria for: JUL Medicaid (category 072) children meeting applicable age requirements (category 032) Medicaid for pregnant women (category 030 or 035) supplemental security income (SSI), except for citizenship or legal alien status, are eligible to receive emergency services Basic Policies

    9. January 2010 9 Service Limitations: Medicaid covers only those emergency medical services furnished in the state of New Mexico. Undocumented individuals must: Be residents of New Mexico Furnish proof of residence to the local county ISD office. Basic Policies

    10. January 2010 10 Eligible individuals (continued) Eligibility determinations are made by local county income support division (ISD) offices. After the receipt of emergency services the patient or responsible party is responsible for completing an application at the local county ISD office and for providing all necessary documentation to prove that he or she meets the applicable eligibility criteria no later then the last day of the third month following the month in which the alleged emergency services were received. Basic Policies

    11. January 2010 11 Eligible individuals (continued) If an application is denied or an application for Medicaid coverage is not filed by the last day of the third month following the month in which the alleged emergency services were received, the individual is responsible for payment of the provider bill and can be billed directly for payment by the provider. Individuals are responsible for notifying providers of the approval or denial of a Medicaid application. Basic Policies

    12. January 2010 12 Coverage Criteria Emergency is defined as: a medical condition, including all emergency labor and delivery includes emergency inductions, scheduled and unscheduled cesarean sections, and routine deliveries Basic Policies

    13. January 2010 13 Coverage Criteria (continued) acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in one of the following: Individuals death Placement of the individuals health in serious jeopardy Serious impairment of bodily functions, or Serious dysfunction of any bodily organ or part. Basic Policies

    14. January 2010 14 Coverage Criteria Only medical services that are necessary to treat and/or evaluate a condition that meets the definition of emergency are covered for the duration of the emergency. After delivery, a child can have legally documented, or citizenship status because of its birth in the United States and, therefore, is not eligible for emergency services for undocumented aliens. Basic Policies

    15. January 2010 15 Coverage Criteria (continued) Once the mother is approved for EMSA and notification is established from the medical provider of the newborn information, the ISD worker may open a Category 31 Medicaid case, as eligibility for the newborn may be deemed eligible under the mothers Medicaid status for the first year. Basic Policies

    16. January 2010 16 Coverage Criteria (continued) After one year, the childs own eligibility must be established pursuant to the requirements for proof of citizenship and identity. If ISD is not notified within the first 30 days after birth, the category will be 32 and will need to be applied for. Determination of coverage is made by MAD or its designee. Basic Policies

    17. January 2010 17 Coverage Criteria (continued) If the mother fails to report the birth in a timely manner to the county Income Support Division Office (ISD), the state agency that determines Medicaid eligibility for infants, payment to providers rendering services may be delayed. Basic Policies

    18. January 2010 18 Noncovered services Long term care Organ transplants Rehabilitation services Surgical procedures, other than unscheduled emergency procedures Basic Policies

    19. January 2010 19 Noncovered services Psychiatric or psychological services Durable medical equipment or supplies Eyeglasses Hearing aids Outpatient prescriptions Podiatry services Prenatal care Well child care Basic Policies

    20. January 2010 20 Noncovered services Routine dental care Routine dialysis services Any medical service furnished by a border or out-of-state provider Non-emergency transportation, and Preventive care Basic Policies

    21. January 2010 21 As of December 1st, 2009 all EMSA claims are to be filed directly to ACS along with a copy of the MAD 310, which is supplied by the ISD Administration, plus all medical documentation to support the medical emergency. Mail to the following address ACS, Inc. P.O. Box 26500 Albuquerque, NM 87125-6500 Billing Policies

    22. January 2010 22 Diagnosis codes must be used and are obtained in the International Classification of Diseases, Clinical Modifications, 9th edition, Vol. 1 and 2 or its successor. Procedure codes to be used are contained in the Physicians Current Procedural Terminology (CPT) manual and the Healthcare Common Procedure Coding System (HCPCS) Level II codebook. Billing Policies

    23. January 2010 23 Troubleshooting EMSA Claims How should provider follow-up on this claim? Allow 4 weeks from the date the claim(s) were submitted to ACS to appear on the Web Portal. Claims may suspend for a manual review and authorization; please allow more time for final adjudication. If there is no claim in the Web Portal at that time resubmit the claim for processing.

    24. January 2010 24 Troubleshooting EMSA Claims If claim denies for billing issues, how does the provider resubmit the claim? When an EMSA claim denies, the corrected claim containing the PA number must be resubmitted with the and MAD 310 and proof of timely filing to ACS. If the denial 1301 is on the EOB Please refer to the letter sent by Molina TPA/UR. For questions regarding this denial of emergency services contact Molina. Call Molina TPA (505) 348-0311 (in Albuquerque) (866) 916-3250, (toll free) For all other denials in which youre unsure how to correct the problem call ACS (Provider Relations) and a representative will assist you.

    25. January 2010 25 Troubleshooting EMSA Claims Can an EMSA claim be adjusted? No! Each specific claim is authorized individually.

    26. January 2010 26 Troubleshooting EMSA Claims How does the provider handle an EMSA claim that has paid and now has charges that need to be added to that claim? The original claim needs to be voided. Then all medical records, a new claim with Proof of timely filing, the MAD 310, and a cover letter explaining that this is a resubmission and the first claim was incorrect need to be resent to ACS.

    27. January 2010 27 Follow these billing procedures and you will be a happy, successful EMSA biller.

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