IHCP Updates

1. IHCP Updates HP Provider Relations February 2011

2. Agenda Objectives Transition and Testing for American National Standards Institute (ANSI) Version 5010 National Correct Coding Initiative Dental Cap Diabetic Supply List Therapy Service Changes Vision Service Changes Long Term Care Changes Changes to Reimbursement Rates Presumptive Eligibility/Notification of Pregnancy Prior Authorization for Inpatient Hospitals Universal Prior Authorization Form Software Download for Omni Users Customer Service Inquiries Helpful Tools Questions

3. Objectives Know about the transition to the Health Insurance Portability and Accountability Act (HIPAA) version 5010 Understand NCCI and the impact on claim processing Know about the changes/updates related to your provider type Understand the Prior Authorization process for inpatient admissions Become aware of the universal prior authorization form Know about the need to update the Omni system

4. Explain HIPAA 5010

5. HIPAA 5010 The mandatory compliance date for ANSI version 5010 and the National Council for Prescription Drug Programs (NCPDP) version D.0 for all covered entities is January 1, 2012 IHCP 5010 Companion Guides and Upcoming Changes document are available at www.provider.indianamedicaid.com • Upcoming Changes document contains only segments that are updated, added, or deleted

6. HIPAA 5010 If submitting claims to the IHCP, you need to be aware of the upgrades to prevent delay in payment Transactions affected by this upgrade: • Institutional claims (837I) • Dental claims (837D) • Medical claims (837P) • Pharmacy claims (NCPDP) • Eligibility verifications (270/271) • Claim status inquiry (276/277) • Electronic Remittance Advices (835) • Prior authorizations (278) • Managed Care enrollment (834) • Capitation payments (820)

7. Testing Information All trading partners currently approved to submit 4010 and NCPDP 5.1 versions are required to test and be approved for 5010 and D.0 transaction compliance • Scheduled testing started in January for software vendors, clearinghouses, and billing services Providers that exchange data with the IHCP using an IHCP- approved software vendor will not need to test Providers that submit data via Web interChange do not need to test • Each trading partner is required to submit a new Trading Partner Agreement

8. What You Need To Do If you bill IHCP directly • Begin the process to upgrade to the ANSI 5010 or NCPDP D.0 versions If you are using a billing service or clearinghouse • Find out if they are preparing for the HIPAA upgrades to ANSI v5010 and NCPDP vD.0 Questions should be directed to INXIXTradingPartner@hp.com OR Call the EDI Solutions Service Desk • 1-877-877-5182 or (317) 488-5160 Watch for additional information in bulletins, banner pages, and newsletters at www.indianamedicaid.com

9. Define National Correct Coding Initiative

10. National Correct Coding Initiative In the 1990s, the Centers for Medicare & Medicaid Services (CMS) developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment NCCI has been in place for many years and most providers are familiar with the editing methodologies with Medicare Also included in NCCI editing are: • Claims with Third Party Liability (TPL) amounts • Claims denied by the primary insurance What is it?

11. National Correct Coding Initiative Initial editing encompasses three basic coding concepts • This pair of edits represent two codes that normally should not be reported together. • Column One indicates the correct code, and Column Two indicates the incorrect or inappropriate code(s) in relation to the Column One code. Column One Column Two • Identifies procedures that cannot be reasonably performed on the same day because they are mutually exclusive. • These procedures cannot be performed at the same anatomic site or same patient encounter. Mutually Exclusive Procedures (ME) • The maximum units of services that a provider would report under most circumstances for a single member on a single date of service. • If the providerbills for moreunits than the amount of units established by MUE for that procedure code, that detail line will be denied when the claim is processed for NCCI editing. Medically Unlikely Edits (MUE)

12. National Correct Coding Initiative • NCCI will affect providers submitting the following: • Institutional outpatient claims • Professional claims • Professional claim implementation began January 27, 2011 • Institutional claim implementation begins April 1, 2011 • Watch for more information in your bulletins, banner pages, and newsletters at www.indianamedicaid.com • The NCCI policy manual is available at http://www.cms.gov/NationalCorrectCodInitEd Who will be affected?

13. Explain Dental Cap

14. Dental Cap Limit Effective with dates of service January 1, 2011 $1,000 Cap • Calendar year cap • Applies to members 21 and above • Previous cap was for members 19 and over • All Indiana Health Coverage Programs (IHCP), including Traditional Medicaid, Hoosier Healthwise, and Care Select • Web interChange displays amount of cap met • Exceptions • Hospital place of service 21 or 22 • Any service provided in a hospital setting is exempt from the cap Additional information may be found in BT201059

15. Describe Diabetic Supply List

16. Preferred Diabetic Supply List (PDSL) Changes effective for dates of service January 1, 2011, and after • Provider Types • Durable Medical Equipment (DME) • Pharmacy • Preferred Vendors • Abbott Diabetes Care • Roche Diagnostics

17. Preferred Diabetic Supply List (PDSL) Changes effective for dates of service January 1, 2011, and after • Blood Glucose Monitors • Freestyle Life System • Freestyle Freedom Lite System • Precision Xtra Meter • Accu-chek Aviva Care • Diabetic Test Strips • Freestyle Lite Test Strips • Precision Xtra Test Strips • Accu-chek Aviva Care Diabetic Test Strips Supplies list

18. Preferred Diabetic Supply List (PDSL) • Members Affected • All Indiana Medicaid members • Healthy Indiana Plan members • Members currently utilizing a blood glucose monitor were required to convert to the preferred products • There was no additional cost to the member or provider • Members continue to have no copayment for blood glucose monitors and diabetic test strips, regardless of their inclusion on the PDSL • Members subject to spend-down are still responsible for any spend-down liability after the claim adjudicates • Members were notified by mail of the changes and directions on how to obtain a new monitor at no cost • Providers should continue to provide training to members in regard to the preferred blood glucose monitors and/or refer the members to the manufacturer of the product

19. Preferred Diabetic Supply List (PDSL) Claims for dates of service on or after January 1, 2011 • Professional Claims Affected • CMS-1500 Paper Claims • Web interChange • Batch (837P Transactions) Claims • Claim Submission • Claims must be submitted to the fee-for-service (FFS) medical benefit • Includes all Indiana Medicaid Members • Includes all Healthy Indiana Plan members Billing guidelines

20. Preferred Diabetic Supply List (PDSL) National Drug Code (NDC) Requirement • N4 qualifier required • Corresponding 11-digit NDC required • Utilize the 5-4-2 format • Unit of measure • UN • Required on all claims • Medicare Crossover claims • Third Party Liability (TPL) claims Billing guidelines

21. Preferred Diabetic Supply List (PDSL) • Procedure Codes Utilized • E0607 – Home blood glucose monitor • A4253 – Blood glucose test or reagent strips for home blood glucose monitor, per 50 strips • Modifiers • NU and RR modifiers are not used for E0607, E0607 U1, A4523 and A4523 U1 for supplies that are on the PDSL • Effective with dates of service January 1, 2011, and after • Exception – Medicare crossover claims require the appropriate modifier • Exception – TPL claims for non-preferred PDSL require the U1 • Prior Authorization • Claims for blood glucose monitors and test strips not included in the PDSL will require prior authorization • Diabetic test strip quantities exceeding 200 strips per month require prior authorization Additional information can be found in BT201055 Billing guidelines

22. Define Therapy Service Limitations

23. Therapy Service Limitations Effective with dates of service January 1, 2011, new limits for physical, occupational, and speech therapy were imposed Twenty-five visit limit • Per rolling 12-month period • Applies to members 21 and older • Prior authorization (PA) will no longer be required for physical therapy, occupational therapy, and speech therapy services for members age 21 or older • PA is still required for members under 21 • Limit is for each type of therapy • A “visit” is defined by the type of therapy and date of service. For example, a member receives physical therapy from a provider during a one-hour visit. That member receives physical therapy services defined with procedure codes 97116, 97140, 97530, and 97532 during the visit. This is counted as one “visit” toward the member’s limitation. Additional information may be found in BT201058

24. Describe Vision Services

25. Vision Services Effective with dates of service January 1, 2011, new limits for covered eyeglass benefits One pair per year for recipients under 21 • Previously applied to members under 19 One pair every five years for recipients 21 and over • Previously applied to members over 19 • Previously one pair every two years Affects all IHCP Programs • Traditional Medicaid • Hoosier Healthwise • Care Select Additional information may be found in BT201049 Note: HIP does not cover vision services

26. Explain Long Term Care

27. Long Term Care – Facility Leave Days Effective February 1, 2011, bed hold days are no longer reimbursed Revenue Codes • 180 – nonpaid • 183 – therapeutic leave • 185 – hospital leave Impacts all Indiana Health Coverage Programs Members • Members in nursing facilities were notified Providers should inform members of their bed hold policy • Members may be charged for the bed hold if they choose the service Additional information may be found in BT201061

28. Explain Reimbursement Rates

29. Five Percent Rate Reduction Effective with dates of service January 1, 2011, and after Attendant Care • Based on billing provider type 32 – waiver Additional information may be found in BT201054 Chiropractors • Based on rendering provider specialty 150 • Will occur at the claim level detail Reduction will apply prior to subtracting any third-party liability or spend-down amount Additional information may be found in BT201051 Podiatrist • Based on rendering provider specialty 140 • Will occur at the claim level detail Reduction will apply prior to subtracting any third-party liability or spend-down amounts Additional information may be found in BT201050

30. Transportation New rates effective with dates of service January 1, 2011, and after Five percent reduction • Ambulance transportation providers Ten percent reduction • Non-ambulance transportation providers Reduction will apply prior to subtracting any third-party liability or spend-down amounts Transportation providers are able to access the reduced rates on the IHCP fee schedule at www.indianamedicaid.com Additional information may be found in BT201057

31. Explain Presumptive Eligibility/Notification of Pregnancy

32. Presumptive Eligibility (PE) PE Application • Review application for accuracy prior to submission • Name • Date of birth • Address • Contact HP provider field consultant for corrections on the application to the demographic information listed above • One approved application per pregnancy • Do not override the warning except for: • Pre-term delivery • Abortion • Miscarriage

33. Presumptive Eligibility (PE) Contacting the enrollment broker • As of January 1, 2011 • Members choose a managed care entity (MCE) • Previously, members chose a primary care physician (PMP) • MCE must be chosen the same day application is submitted • MCE will add the PMP when assigned • Eligibility may not reflect a PMP immediately • Claims should be submitted to the MCE listed on the eligibility verification

34. Notification of Pregnancy (NOP) Submitting NOP information • Information cannot be changed once submitted • Review information for accuracy prior to submitting Duplicate NOPs (same woman, same pregnancy) do not qualify for reimbursement Providers will receive an on-screen message if the NOP appears to be a duplicate

35. Explain Prior Authorization

36. Prior Authorization (PA) Effective with admit date of service on January 1, 2011, and after Prior authorization is required for all non-emergent inpatient hospital admissions • Elective or planned inpatient admissions • Applies to members of all ages with Traditional Medicaid and Care Select • Request PA via the telephone • At least two days in advance • Outside of normal business hours, weekends and holidays – within 48 hours of admission • Contact ADVANTAGE Health Solutions for Care Select members assigned to ADVANTAGE at 1-800-784-3981 • Contact MDwise for MDwise Care Select members at 1-866-440-2449 • Contact ADVANTAGE Health Solutions for fee-for-service members at 1-800-269-5720 Elective inpatient hospital admissions

37. Prior Authorization (PA) Excluded from PA requirement • Emergent admissions • Routine Vaginal and C-Section deliveries • Newborn stays • Medicare/Medicaid dual eligible member admissions • Observation Additional information may be found in BT201060 Elective inpatient hospital admissions

38. Define Prior Authorization

39. Prior Authorization (PA) Universal form required effective January 1, 2011 All providers • All IHCP Programs • Traditional • Hoosier Healthwise • Care Select • Healthy Indiana Plan (HIP) PA form and instructions are available at www.indianamedicaid.com under the Forms link Universal prior authorization form

40. Prior Authorization (PA) • Exception • Dental • Dental PA form available on the IHCP website • Pharmacy • Pharmacy PA form available on the IHCP website • Behavioral Health • Traditional Medicaid and Care Select DO use the Universal PA Form • Indicate "Mental Health" or "MRO" in the upper left hand corner • Hoosier Healthwise-Risk Based Managed Care and Health Indiana Plan (HIP) • Use the form authorized by the individual MCE Additional information may be found in BT201045 Universal prior authorization form

41. Prior Authorization (PA) Universal prior authorization form

42. Define Omni Download

43. Omni Download Required Required to obtain correct primary care physician (PMP) information when checking eligibility • Omni will show “No PMP assigned" after upgrade Instructions for download • Refer to BT200711, Table 1.1 • IHCP Provider Manual Chapter 3, Table 3.7 For assistance contact the Omni help desk • (317) 488-5051 • 1-800-284-3548 Additional information may be found in BR201049

44. Define Customer Service Inquiries

45. Customer Service Inquiries Claim Status • Verify claim status on the Web interChange • Claim inquiry Procedure Code Coverage • Verify procedure code coverage, program coverage, and prior authorization requirements on the fee schedule Spend-down Information • IHCP Provider Manual Chapter 2, Section 4 and Chapter 5, Section 5 • Provider Education – Archived Workshop Presentations • Spend-down

46. Find Help Resources Available

47. Helpful Tools IHCP Web site at www.indianamedicaid.com IHCP Provider Manual (Web, CD-ROM, or paper) IHCP Fee Schedule Customer Assistance • 1-800-577-1278, or • (317) 655-3240 in the Indianapolis local area Written Correspondence • P.O. Box 7263Indianapolis, IN 46207-7263 Provider field consultant • http://www.indianamedicaid.com/ihcp/ProviderServices/pr_list_frameset.htm

48. Q&A