Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment...
Transcript of Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment...
![Page 1: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/1.jpg)
Indiana Health Coverage ProgramsDXC Technology
Durable & Home Medical Equipment (DME & HME)
Fee-for-Service
October 2017
![Page 2: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/2.jpg)
2
Session Objectives
• Reference Materials• Provider Healthcare Portal• Service Descriptions• Manual Pricing• Updates• Helpful tools• Questions
![Page 3: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/3.jpg)
3
Reference MaterialsReference material, code tables, fee schedules
![Page 4: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/4.jpg)
4
Reference Materials
• Providers can stay abreast of current developments and research issues:– Banners and bulletins– News and announcements– Provider Reference Materials
• Medical Policy Manual• DME & HME Reference Module
– Code Tables– Subscribe to email notices– Fee schedules
![Page 5: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/5.jpg)
5
Reference Materials
![Page 6: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/6.jpg)
6
New Look for Subscribers!
![Page 7: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/7.jpg)
7
![Page 8: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/8.jpg)
8
DME & HME Reference Module
![Page 9: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/9.jpg)
9
DME & HME Code Tables
![Page 10: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/10.jpg)
10
Procedure Codes Requiring Attachments
![Page 11: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/11.jpg)
11
Professional Fee Schedule
![Page 12: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/12.jpg)
12
Provider Healthcare PortalPortal overview, web-based training, benefit limit details,
Written Correspondence, billing members
![Page 13: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/13.jpg)
13
Provider Healthcare Portal
• What can you do in the Provider Healthcare Portal?– Submit, copy, edit, void claims– Check on status of claims– Verify eligibility– View, print remittance advices– Request prior authorization– Provider enrollment and revalidation– Secure correspondence– And more…..
![Page 14: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/14.jpg)
14
Provider Healthcare Portal Login Page
![Page 15: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/15.jpg)
15
Provider Healthcare Portal User Access
![Page 16: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/16.jpg)
16
Search Payment History
![Page 17: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/17.jpg)
17
Portal – Benefit Limits Details
Example• Benefit limit details listed in Portal eligibility screen:*
– 6113 DME Limited to $2,000 per Recipient per Calendar year– 6114 DME Limited to $5,000 per Recipient per Lifetime– 6085 Incontinence supplies limited to $1950/Rolling Year
*If the limitation does not appear on the eligibility screen, the service is available (based on fee-for-service claim data only)
![Page 18: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/18.jpg)
18
Portal – Benefit Limits Details
Benefit limits are found on the Eligibility page
![Page 19: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/19.jpg)
19
Provider Healthcare Portal
• Web-based training
![Page 20: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/20.jpg)
20
DME, HME, SuppliesProvider Type, Description of Services, Classifications
![Page 21: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/21.jpg)
21
Provider Type
Provider Type 25 Specialty 250 – DME Specialty 251 – HME Must have HME license
Each specialty has it’s own code set
Revalidation required every 3 years: Application fee & Background check FingerprintingRefer to www.indianamedicaid.com > IHCP Provider Type and Specialty Matrix for additional requirements
![Page 22: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/22.jpg)
22
Description of Service
• Equipment that can withstand repeated use, is primarily and customarily used to serve a medical purpose, and generally is not useful to a recipient in absence of illness or injury
• Must be ordered in writing by a physician
• Written order must be kept on file by physician and rendering provider
![Page 23: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/23.jpg)
23
Description of Service
• Items include but are not limited to the following:
• Capped rental items • Inexpensive or other routinely
purchased items• Items requiring frequent or
substantial servicing • Customized items • Prosthetic and orthotic devices • Oxygen and oxygen equipment
![Page 24: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/24.jpg)
24
Capped Rental Items
Capped rental items are procedure codes limited to 15 months of continuous rental• Continuous rental: rental without interruption for a
period of more than 60 days• If rental period exceeds 60 days, and the
interruption reasons are justified, a new PA request must be submitted to begin a new 15-month rental period
• Justification could change in medical necessity, hospitalization, or nursing facility stay
• A change in provider does not cause an interruption in rental period
• Capped rental items are subject to prior authorization
![Page 25: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/25.jpg)
25
Items Requiring Frequent or Substantial Servicing
For items requiring frequent or substantial servicing, IHCP reimburses providers for rental payments only, as long as equipment is deemed medically necessary
• Claims for the purchase of these items are denied• Repair of rental items is responsibility of rental provider
• Table 4 – Procedure Codes for Equipment and Supplies Classified by the IHCP as Needing Frequent and Substantial Servicing
![Page 26: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/26.jpg)
26
Customized Items
Custom equipment: equipment uniquely constructed or substantially modified to meet specific needs of an individual patient, according to description and orders of member’s treating physician• Due to their unique aspects, these
items cannot be grouped with similar items for purposes of payment
• Suppliers must submit documentation of cost of item, including cost of labor and types of materials used in customizing item
• Customized items must be billed using HCPCS code E1399 requires PA
![Page 27: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/27.jpg)
27
Prosthetic and Orthotic Devices
All prosthetic and orthotic devices billed under HCPCS L codes are paid in lump sum amounts and may not be rented• Prosthetic and orthotic devices
billed with HCPCS L codes • Requires PA
All PA reviews based upon medical necessity
![Page 28: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/28.jpg)
28
Oxygen and Oxygen Equipment
IHCP reimburses liquid and gaseous oxygen systems as rental-only items, subject to PA Reimbursement for oxygen contents is
included in reimbursement of oxygen system and is not separately reimbursable for rented systems Oxygen contents are separately reimbursable
when a third party has purchased an oxygen system, or IHCP or third party has rented or purchased a portable oxygen system
Accessories, including but not limited to cannulas, masks, and tubing, are also included in allowance for rented systems and are not separately reimbursable Accessories are separately reimbursable with a
purchased system
![Page 29: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/29.jpg)
29
Manual Pricing
![Page 30: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/30.jpg)
30
Manually Priced Items
Reimbursement for many DME services and supplies, including those that are billed with a non-specific HCPCS code with a description such as unspecified, unclassified, or miscellaneous are based on manual pricing• Manually priced HCPCS codes are
reimbursed at 75% of manufacturer’s suggested retail price (MSRP)
![Page 31: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/31.jpg)
31
Manually Priced Items
• Documentation submitted with each claim may be monitored or subject to a post-payment review
• Manually priced DME, medical supply, and hearing aid procedure codes will continue to be reimbursed at 75% of MSRP
• Codes without an MSRP will be reimbursed at provider’s cost plus 20%
![Page 32: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/32.jpg)
32
Manually Priced Items
• Manufacturer’s retail invoice or suggested retail price (MSRP) is required as acceptable documentation:o Manufacturer’s invoice showing MSRP,
suggested retail price, or retail price o Quote from manufacturer showing MSRP,
suggested retail price, or retail price o Manufacturer’s catalog page showing MSRP,
suggested retail price, or retail price (publication date of catalog must clearly show on documentation)
o MSRP pricing from manufacturer’s website (manufacturer’s web address must be visible on printed documentation from its website)
![Page 33: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/33.jpg)
33
Manufacturer’s Suggested Retail Price
MSRP documentation must include:• Manufacturer’s name clearly visible on header of documentation• MSRP pricing (for example, MSRP/Retail) typed from manufacturer o No handwritten notes or pricing will be accepted
• Description of item• Specific HCPCS code
![Page 34: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/34.jpg)
34
Approved MSRP Documentation
Date Descriptions
Manufacturer’s suggested retail price
Manufacturer’s LogoManufacturer’s Name
![Page 35: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/35.jpg)
35
Approved MSRP Documentation − Quote
![Page 36: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/36.jpg)
36
Approved MSRP Doc. Catalog Page
Catalog page must have publication date
![Page 37: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/37.jpg)
37
Approved MSRP Documentation − Website
![Page 38: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/38.jpg)
38
Updates
![Page 39: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/39.jpg)
39
DME Codes No Longer Billed with NU
• Effective April 28, 2017, the IHCP revised billing guidelines for DME codes billed with NU modifier
• Claims billed with NU will be denied with EOB code 4033-Invalid procedure code modifier combination
• Refer to banner BR201713 for a list of affected codes (most are Q codes)
![Page 40: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/40.jpg)
40
DME & Supplies Covered as Home Health Service
Effective May 1, 2017, the IHCP revised coverage policy for home health services• For coverage of certain DME & supplies as a home health service,
documentation of face-to-face encounter must occur no more than six months before start of service.
• Examples: – Decubitus care equipment– Oxygen and related respiratory equipment– Monitoring devices– Compression devices
Refer to bulletin BT201723 for complete list
![Page 41: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/41.jpg)
41
Red-and-White Claim Form
• Effective January 1, 2018 the IHCP will require the below claim types to be submitting for processing on the appropriate red and white forms.
– CMS-1500 (02-12) – professional claims – UB-04 (CMS-1450) – institutional claims
• The IHCP will no longer accept copied (black and white) claim forms on or after January 1, 2018.
• Claims not received on the red-and-white claim form on or after January 1, 2018, will be returned to the provider.
![Page 42: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/42.jpg)
42
Helpful Tools
![Page 43: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/43.jpg)
43
Helpful Tools
• IHCP website at indianamedicaid.com– IHCP Provider Reference Modules– Medical Policy Manual
• Customer Assistance available 8am-6pm EST Monday –Friday
– 1-800-457-4584• IHCP Provider Relations Field Consultants– See the Provider Relations Field Consultants page at
indianamedicaid.com • Secure Correspondence via the Provider Healthcare
Portal • Written Correspondence
– DXC Technology Provider Written CorrespondenceP.O. Box 7263Indianapolis, In 46207-7263
![Page 44: Durable & Home Medical Equipment (DME & HME) hme walkthrough.pdfDurable & Home Medical Equipment (DME & HME) Fee-for-Service October 2017 2 Session Objectives • Reference Materials](https://reader034.fdocuments.net/reader034/viewer/2022042810/5f99a0b94455bb005f01123c/html5/thumbnails/44.jpg)
44
QuestionsFollowing this session please review your schedule for the next session you
are registered to attend