Home Health Caremanuals.medicaidalaska.com/docs/dnld/Tr_Home_Health_Care.pdf• Pertinent diagnosis...
Transcript of Home Health Caremanuals.medicaidalaska.com/docs/dnld/Tr_Home_Health_Care.pdf• Pertinent diagnosis...
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Home Health Care April 2019
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Overview
• Provider Enrollment
• Member Eligibility
• Covered Services
• Billing
• Additional Information
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Provider Enrollment
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Enrollment Requirements
• Providers must be certified as a home health agency for Medicare purposes in the
jurisdiction where they are providing services
• Enroll as a home health care provider with AK Medicaid
• If providing home health care out of state, must be enrolled in the Medicaid program in
the jurisdiction where they are providing services
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Enrollment Requirements (cont.)
Provider types the department will pay for home health services:
• Public or private organization may provide comprehensive services
• RHC/FQHC may provide limited home health services
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Update Provider Information
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Recordkeeping
• Recordkeeping requirements are documented in the Individual Provider Agreement and
Tax Certification and Group Provider Agreement and Tax Certification
• Although most recordkeeping requirements are consistent for all providers, some
requirements are provider-type specific
• Providers must maintain complete and accurate clinical, financial, and other relevant
records to support the care and services for which they bill Alaska Medical Assistance for a
minimum of 7 years from the date of service
• Providers are subject to audits, reviews and investigations
Providers must ensure their staff, billing agents, and any other entities responsible for any
aspect of records maintenance meet the same requirements.
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Member Eligibility
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Member Eligibility
Always verify member eligibility by using one of the following options:
• Request to see the member's eligibility coupon or card that shows the current month of
eligibility; photocopy for your records
• Call Automated Voice Response System (AVR):
– 855.329.8986 (toll-free)
• Verify via Alaska Medicaid Health Enterprise website
– http://medicaidalaska.com
• Fax complete Recipient Eligibility Inquiry Form - General
– 907.644.8126
• Submit a HIPAA compliant 270/271 electronic Eligibility Inquiry transaction
• Call Provider Inquiry
– 907.644.6800, option 1 or 800.770.5650, option 1, 1 (toll-free)
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Member Eligibility
Code Category FQHC RHC
11 Medicaid for Pregnant women X X
20 Family Medicaid or APA related Medicaid X X
24 Institutional Long Term Care Medicaid X
30/31 Waiver for adults with physical and developmental disabilities X X
34 Waiver APA/QMB X X
40/41 Older or disabled adult with waiver and Medicaid X X
44 Older or disabled adult with waiver Medicaid, APA and QMB X X
50 Medicaid for children under 21 who are not in state custody X X
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Member Eligibility
Code Category FQHC RHC
51 Medicaid for children under 21 who are in state custody,
including Title IV-E foster care
X X
52 4 months of Medicaid for members otherwise ineligible due to
earned income
X X
54 Medicaid-only for disabled child receiving SSI X X
69 APA/QMB – full Medicaid and QMB X X
70/71 IDD Waiver X X
74 IDD waiver, APA and Medicare X X
80/81 Medically complex children-waiver X X
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Covered Services
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Service Authorization
• Initial visit for evaluation is covered without service authorization
• All other services require SA
• SA must be requested on department form and include a written statement by the
attending physician that:
– Explains the need for home health services, including the reason services cannot be
performed in a clinic, outpatient setting, or physician’s office
– Includes medical recommendations for a plan of care provided on an ongoing basis or
after acute care
• SA will not be for longer than 60 days
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Face-to-Face Encounter
• For initiation of home health services, the patient must have a face-to-face encounter with an appropriate
practitioner, including:
– Physician
– Nurse Practitioner or Clinical Nurse Specialist
– Physician Assistant, under supervision of a physician
– For members admitted to home health immediately after an acute or post-acute stay, the attending
acute or post-acute physician
• Face-to-face encounter must be related to the primary reason the member requires home health
services, and must occur within 90 days before or 30 days after the start of services
• When the face-to-face encounter is provided by a non-physician provider, the clinical findings must be
communicated to the ordering physician
• Clinical findings must be incorporated into a written or electronic document included in the member’s
medical record
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Plan of Care
Plan of care must include:
• Pertinent diagnosis including mental status
• Types of services and equipment required
• Frequency of visits
• Prognosis for the recipient
• Analysis of the recipient’s rehabilitation potential
• Description of the member’s functional limitations
• Activities permitted to the member
• The member’s nutritional requirements
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Plan of Care (cont.)
• Plan of care must include:
– Member’s medication and treatments
– Any safety measures to protect the recipient against injury
– Instructions for a timely discharge and referral
• If plan of care cannot be completed until after evaluation, physician shall make additions or
modifications to the original POC as necessary to reflect the outcome of the evaluation
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Plan of Care Review
• The attending physician shall review the POC and initial and comprehensive assessments:
– At least once during the SA period
– More frequently if member’s condition has a significant change
– If member is discharged from home health agency and returns within the SA period
• Physician shall review need for supplies at least annually or more frequently for certain
items
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Initial Assessment
• To determine immediate care and support of the member
• Must be completed by an RN
• Must be completed by no more than:
– 48 hours after referral
– 48 hours after member’s return to place of residence
– Or by physician-ordered start of care date
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Comprehensive Assessment
• Must be completed by an RN
• Consistent with member’s immediate care and support needs
• No later than 5 days after the date care starts
• Must include a review of each medication the member currently uses in order to
determine:
– Significant side effects
– Ineffective drug therapy
– Duplicate drug therapy
– Member’s noncompliance with drug therapy
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Therapy Assessment
• If speech-language pathology or physical or occupational therapy is the only service
ordered by the physician, a speech-language pathologist or physical or occupation
therapist, as appropriate, may complete the initial and comprehensive assessments
• In this case, the medication review is not required as part of the comprehensive
assessment
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Home Health Services
• Alaska Medicaid covers home health services provided to a member in their place of
residence which may include an assisted living home licensed under AS 47.32
• All Home Health Services must be prescribed by a licensed physician as part of an
approved plan of care
• Services may include:
– Intermittent or part-time skilled nursing services provided by an RN or an LPN
– Home health aides services provided under RN supervision
– Physical or occupational therapies, speech-language pathology, and audiology services
provided by or under the supervision of a qualified practitioner
– Suitable home medical supplies
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Covered Revenue Codes
Subject to a provider’s scope of certification, license, or accreditation, AK Medicaid covers
these revenue codes for home health agencies:
• 0001
• 0270
• 0421
• 0431
• 0441
• 0551
• 0571
• 0572
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Rural Health Clinic Services
• Skilled nursing services provided by an RN
• According to written orders from the member’s physician
• Within scope of the provider’s license
• Provided by an enrolled rural health clinic
• When the location of the member’s place of residence is not served by any public or
private home health agency
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Place of Residence
• Services must be provided to the member in their place of residence
• May include an assisted living home
• Does not include a hospital, skilled nursing facility or intermediate care facility
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Billing
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Claims Submission Methods
There are several billing options for Alaska Medical Assistance providers.
• Alaska Medicaid Health Enterprise
• 837I Transaction (electronic claim using billing software)
– Companion Guide: http://medicaidalaska.com
– Implementation Guide (referred to as TR3): http://www.wpc-edi.com
• Payerpath (electronic claim)
• UB-04, Insitutional Health Insurance Claim Form (paper claim)
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NDC Pricing
• Payment for physician-administered drugs will be based on NDC and NDC quantity
• Exception- Payments currently based on per diem rates or a percentage of provider
charges
• Bill the NDC for the actual drug that is administered
• Record the NDC into the patient record
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NDC Claims
• Identified on 837I and UB-04 claims by revenue codes
• Identified on 837P and CMS-1500 claims by HCPCS codes
– Usually “J” codes
• Include on your claims:
– NDC number
– NDC units of measurement
– Numeric quantity
– Corresponding HCPCS values and units
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NDC Structure
NDC consists of 11 digits in three sections
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NDC Structure (cont.)
• Product label indicates: 54225-1798-29
• Submit on claim as: 54225179829
• Product label indicates: 452-72-89
• Submit on claim as: 00452007289
• Product label indicates: 45-6-9
• How would you submit this on a claim?
• The correct answer is 00045000609
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NDC Units
NDC billing unit standard:
• UN = unit
• ML = milliliter
• GR = gram
• F2 = International Unit
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Timely Filing
• All claims must be filed within 12 months of the date you provided services to the member
• The 12-month timely filing limit applies to all claims, including those that must first be filed
with a third-party carrier
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Additional Information
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Additional Resources
Alaska Medicaid Health Enterprise website at http://medicaidalaska.com
• Information necessary for successful billing
• Includes provider-specific Medicaid billing manuals and fee schedules
You may also call:
• Provider Inquiry
– Eligibility only – 907.644.6800, option 1,2 or 800.770.5650 (toll-free), option 1,1,2
– Claim status and other inquiries – 907.644.6800, option 1,1 or 800.770.5650 (toll-free),
option 1,1,1
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