HP Provider Relations October 2011 Transportation Guidelines.

HP Provider Relations

October 2011

Transportation Guidelines

2 Transportation Guidelines October 2011

Agenda– Session objectives

– Provider enrollment responsibilities

– Types of transportation services

– Transportation specialties and billing codes

– QMB Only/Also

– Destination modifiers

– Prior authorization

– Mileage, multi-passengers and attendants

– Copayment amounts and exemptions

– Common denials

– Frequently asked questions

– Helpful tools

– Questions and answers


Session Objectives

At the end of this session, providers will understand:

–Enrollment and recertification document requirements

–Impact of QMB-only

–Importance of origin and destination modifiers

–Prior authorization requirements

–How to bill for mileage, attendants, and waiting time

–Required copayments and copayment exemptions

–How to resolve common claim denials


LearnEnrollment Requirements


Enrollment Responsibilities

– Providers should reference the Provider Type and Specialty Matrix to determine the documentation required to enroll in, or recertify for the Indiana Health Coverage Programs (IHCP)• http://provider.indianamedicaid.com/ihcp/ProviderServices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf

– Once enrolled, transportation providers must recertify annually or based upon permits, certificates, and liability insurance coverage periods

– Two reminder letters are sent to the providers, 60 and 30 days prior to the recertification date• To ensure Recertification Notices are received, all addresses must be kept up to date on the provider profile

http://provider.indianamedicaid.com/ihcp/ProviderServices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf

http://provider.indianamedicaid.com/ihcp/ProviderServices/pdf/TR473-IHCPProviderTypeSpecialtyMatrix.pdf



Seven specialties are associated with transportation providers: • 260 – Ambulance

• 261 – Air ambulance

• 262 – Bus

• 263 – Taxi

• 264 – Common carrier ambulatory services (CAS)

• 265 – Common carrier nonambulatory services (NAS)

• 266 – Family member


260 – Ambulance261 – Air ambulance


– A copy of the Emergency Medical Services (EMS) Commission certificate, based on certificate end date, is needed for enrollment and for the annual recertification


262 – Bus


– The Motor Carriers Services (MCS) certificate issued by the Indiana Department of Revenue is required for both enrollment and annual recertification in the IHCP


263 – Taxi


– A document showing operating authority from a local governing body; for example, a city taxi or livery license

– A copy of retail merchant’s certificate (unless nonprofit status)

– A copy of driver’s licenses for all drivers

– Proof of insurance indicated by local ordinances or, if unspecified by local ordinance, a minimum of $25,000/$50,000 of public livery insurance covering all vehicles used in the business

– Recertification:• Must submit a copy of documentation from the operating authority from the local

governing body (city taxi or livery license)

• Must submit a copy of the renewed insurance policy prior to current insurance policy expiration date


264 – Common carrier ambulatory services (CAS)265 – Common carrier nonambulatory services (NAS)


For profit• Motor Carrier Services certificate

from the Indiana Department of Revenue

• Copy of a valid driver’s license

Not-for-profit• Certification of not-for-profit status

from the Internal Revenue Service (IRS)

• Proof of insurance

• Copy of a valid driver’s license


266 – Family Member


– Approval from the local office of the Division of Family Resources (DFR)

– Proof of insurance

– A copy of a valid driver’s license


DefineTypes of Transportation Services


Types of Transportation Services

– Advanced Life Support – ALS• Care given at the scene of an accident, act of terrorism, or illness; care given during

transport; care given at the hospital by a paramedic or emergency medical technician-intermediate; and care that is more advanced than the care usually provided by an emergency medical technician or an emergency medical technician-basic advanced

– Basic Life Support – BLS• BLS services do not include invasive medical care techniques or advanced life support

– Commercial or Common Ambulatory Service – CAS• Ambulatory (walking) members to or from an IHCP covered service

– Nonambulatory Service (Wheelchair Van) – NAS• Nonambulatory services when a member must travel in a wheelchair to or from an

IHCP-covered service

– Taxi• Taxi providers transport ambulatory members and may operate under authority from a

local governing body (city taxi or livery license)


Definition of a Trip

– For billing purposes, a trip is defined as transporting a member from the initial point of pick-up to the drop off point at the final destination

– Transportation must be the least expensive type of transportation available that meets the medical needs of the member

– Trips must be billed according to the level of service rendered and not according to the vehicle type

– Providers must bill for all transportation services provided to the same member on the same date of service on one claim form


Definition of a Trip

– If the provider makes a round trip for the same member, same date of service, and same level of base code, both runs should be submitted on the same detail with two units of service to indicate a round trip

– Additionally, all mileage for the trip must be billed on the one detail with the total number of miles associated for the roundtrip

– If the provider transports a member on the same date of service, but different trip levels (for example the “to” trip was a CAS trip, and the “return” trip was a NAS trip, with mileage for each base), these base trips must be billed on two different claim forms with the corresponding mileage for each base


Multiple Destinations

– If the member is transported to multiple points in succession, the provider may not bill for a trip between each point of the destination

– The following examples offer explanations of this concept: • Example 1: A vehicle picks up a member at home and transports the member to the

physician’s office. This is a one-way trip.

• Example 2: A vehicle picks up a member from home and transports the member to the physician’s office. The provider leaves, and later the same vehicle picks the member up from the physician’s office and transports the member back to the member’s home. This is considered two one-way trips.

• Example 3: A vehicle picks the member up from the physician’s office and transports the member to the laboratory for a blood draw, waits outside the laboratory for the member, and then transports the member home. This is a one-way trip, even though there was a stop along the way. A stop along the way is not considered a separate trip.


PerformBilling for Services


260 – Ambulance

Billing Codes

Code Description

A0427 Advanced life support (ALS) emergency transport, level 1, one or more interventions

A0426 ALS nonemergency transport, level 1, one or more interventions

A0428 Basic life support (BLS), nonemergency transport

A0429 BLS, emergency transport

A0225 Neonatal transport, ambulance service, base rate one way

CPT copyright 2010 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.


260 – Ambulance

Billing Codes

Code Description

T2003 ALS nonemergency transport; level 1 (common carrier ambulatory)

A0130 ALS nonemergency transport; level 1 (common carrier nonambulatory)

T2003 BLS nonemergency transport; (common carrier ambulatory)

A0130 BLS nonemergency transport; (nonambulatory)

A0425 U1 U2 Ground mileage, per statute mileLevel 1 (ALS)Level 2 (BLS)

A0420 U1 Ambulance service - waiting time ALS one-half (1/2) hour increments

A0420 U1 Ambulance service - waiting time BLS one-half (1/2) hour increments


261 – Air ambulance

Billing Codes

Code Description

A0431 Ambulance service, conventional air service, transport, one way (rotary wing)

A0430 Ambulance service, conventional air service transport, one way (fixed wing)

A0436 Rotary wing air mileage, per statute mile

A0431 QL Ambulance service, conventional air service, transport, one way (rotary wing); if the member is pronounced dead after takeoff to point of pickup


261 – Air ambulance, A0431, A0431 QL, A0436

Billing Guidelines

– Effective for rotary wing air ambulance: for dates of service on or after December 25, 2009, providers are to bill for both the base rate and mileage code

– Rotary wing air ambulance claims no longer require an attachment for a cost invoice after January 1, 2010

– Prior to January 1, 2010, rotary wing air ambulance claims still require an attachment

– Each code is reimbursed at a specific rate per the IHCP fee schedule

– Refer to IHCP Provider Manual, Chapter 8, Section 4

http://provider.indianamedicaid.com/ihcp/Publications/MaxFee/fee_schedule.asp


262 – Bus

Billing Codes

Code Description

A0110 Nonemergency transportation and bus, intrastate, or interstate carrier


263 – Taxi

Billing Codes

Code Description

A0100 U4 Nonemergency transportation – taxi, suburban

A0100 UA Taxi – 0-5 miles

A0100 UB Taxi – 6-10 miles

A0100 UC Taxi – 11 miles and up

A0100 TT UA Taxi – 0 to 5 miles, multi-passenger

A0100 TT UB Taxi – 6 to 10 miles, multi-passenger

A0100 TT UC Taxi – nonregulated, multi-passenger, 11 miles or more

A0100 TK UA Taxi – 0 to 5 miles, accompanying parent or assistant

A0100 TK UB Taxi – 6 to 10 miles, accompanying parent or assistant

A0100 TK UC Taxi – nonregulated, accompanying parent or assistant, 11 miles or more


263 – Taxi

Billing Guidelines

– Taxi providers cannot transport outside the jurisdiction designated by their city taxi license

– To transport outside the jurisdiction, the taxi provider must be enrolled as a common carrier (provider specialties 264 and 265)

– If a taxi transports across county borders, the Indiana Department of Revenue’s Motor Carrier Services Division must certify as a common carrier


264 – Common carrier ambulatory service (CAS)

Billing Codes

Code Description

T2003 Common carrier ambulatory service – base rate

T2004 Common carrier ambulatory service – multiple passenger

T2001 Common carrier ambulatory service – accompanying parent or assistant, base rate

A0425 U3 CAS mileage

T2007 U3 Level 3 CAS waiting time - in one-half (1/2) hour increments


265 – Common carrier nonambulatory services (NAS)

Billing Codes

Code Description

A0130 Wheelchair – Common carrier nonambulatory, base rate

A0130 TT Wheelchair – Common carrier nonambulatory, multiple passenger, base rate

A0130 TK Wheelchair – Common carrier nonambulatory, accompanying parent or attendant, base rate

A0425 U5 NAS Mileage

T2007 U5 Waiting time in one-half (1/2) hour increments


266 – Family member

Billing Codes

Code Description

A0090 Mileage for family member automobile transportation


Qualified Medicare beneficiary (QMB)

Billing Guidelines

– QMB members are eligible for Medicare and Medicaid• The State pays the premium for Medicare Part B

– Two Types:• QMB-Only – The IHCP pays “only” the Medicare coinsurance and deductible

−QMB-Only members do not have transportation coverage for transportation services that are not covered by Medicare

• QMB-Also – The IHCP “also” pays for Medicare noncovered services in addition to the coinsurance and deductible−Services must be covered by Medicaid to be reimbursed

– Transportation providers must have QMB-Only members sign a waiver prior to furnishing services not covered by Medicare

– The IHCP can pay for covered transportation services for QMB-Also members without a waiver


Destination modifiers

Billing Guidelines

– Providers must include the origin and destination modifiers with the base rate procedure codes

– The first character of the two-digit modifier indicates the transport’s place of origin

– The second character indicates the destination

– When a member is transported by more than one transportation company on the same date of service, use of the modifiers helps to prevent one of the claims from denying as a duplicate of the other provider’s claim

– A list of appropriate modifiers can be found in the IHCP Provider Manual in Chapter 8, Section 4

http://provider.indianamedicaid.com/ihcp/manuals/chapter08.pdf


Destination modifiers

Billing Guidelines

Modifier Description

D Diagnostic or therapeutic site, other than P or H

E Residential, domiciliary, or custodial facility (nursing home, not SNF)

G Hospital-based dialysis facility (hospital or hospital-related)

H Hospital

I Site of transfer between types of ambulance

J Nonhospital-based dialysis facility

N Skilled nursing facility (SNF)

P Physician office

R Residence

S Scene of accident or acute event


UnderstandPrior Authorization Requirements


Prior Authorization Requirements

– Trips exceeding 20 one-way trips per rolling 12-month period require prior authorization (PA)

– Other services that require PA:• Air ambulance transportation

• Airline transportation

• Train transportation

• Bus transportation

– Interstate transportation or transportation services rendered by a provider located out-of-state in a nondesignated area


20 one-way trip - exemptions from PA requirement

PA Requirements

– Emergency ambulance services

– Hospital admission or discharge• Transportation to a hospital for admission or from a hospital to home after discharge is

exempt from 20 one-way trip limitation

• All interhospital transportation services, except when the member has been discharged from one hospital for admission to another hospital are non-covered

– Members on renal dialysis• Must have diagnosis code V56.0, V56.1, or V56.8

– Members in nursing homes• Must have diagnosis code V70.5

– Accompanying parent or attendant, and additional attendant• Procedure codes are excluded from 20 one-way trip limitation


PA Requirements

– Trips of 50 miles or more one way require PA

– When requesting PA for trips that are greater than 50 miles one way, providers need to make sure they request authorization for the: • Base rate

• Mileage

• Wait time

– Signature stamps• Providers may use signature stamps on the PA

request form


Traditional Medicaid fee-for-service

PA Contacts

– Traditional Medicaid fee-for-service PA requests are processed by ADVANTAGE Health SolutionsSM

P.O. Box 40789Indianapolis, IN 46240• 1-800-269-5720

• 1-800-689-2759 (Fax)

– Submit PA requests on Web interChange PA Submission for fastest way of obtaining PA


Care Select

PA Contacts

Each care management organization (CMO) is responsible for processing PA requests for its respective Care Select members:

–MDwiseP.O. Box 44214Indianapolis, IN 46244-0214

• 1-800-356-1204

• 1-877-822-7186 (Fax)

–ADVANTAGE Health SolutionsP.O. Box 80068Indianapolis, IN 46280

• 1-800-784-3981

• 1-800-689-2759 (Fax)


Risk-based managed care (RBMC)

PA Contacts

– Providers must direct transportation service requests for RBMC members to the appropriate managed care entity (MCE)

– Managed Health Services (MHS)• LCP Company provides services, but providers must call MHS for PA and notification

of transportation needs• 1-877-647-4848• managedhealthservices.com

– MDwise• Call MDwise for PA and notification of transportation needs• 1-800-356-1204• mdwise.org

– Anthem• 1-800-508-7230 LCP Company• Or Anthem 1-866-408-6132• anthem.com


UnderstandMileage, Multiple Passengers, Attendants, and Waiting Time


Mileage

– Transportation providers are expected to transport members along the shortest most efficient route to and from a destination

– All transportation providers must document mileage on the driver’s ticket using odometer readings or mapping software programs

– Reimbursement is available for mileage, in addition to the base rate, under the following circumstances:• Ambulance providers are reimbursed for loaded mileage for each mile of the trip

regardless of the type level of service being billed

• CAS and NAS providers are reimbursed for loaded mileage when the member is transported more than 10 miles one way

• Taxi providers are not reimbursed for mileage and are not required to submit mileage with their claim; however, the mileage must be documented


Mileage

– Although the first 10 miles of a CAS or NAS trip are automatically deducted from each one-way trip, CAS and NAS providers must bill for all mileage, including the first 10 miles to ensure proper reimbursement

– For trips less than 10 miles, the provider is not required to bill mileage; however, if mileage is billed, the mileage will process as a denied line item

– Providers may bill fractional miles or round to the nearest mile, for example, 15.7 miles can round to 16 miles

– Mileage codes and descriptions:• A0425 U1 ALS ground mileage, per statute mile • A0425 U2 BLS ground mileage, per statute mile • A0425 U3 CAS ground mileage, per statute mile • A0425 U5 NAS ground mileage, per statute mile


Multiple Passengers

– When two or more members are transported simultaneously from the same county to the same vicinity for medical services, the second and subsequent member transported in a single CAS or NAS vehicle is reimbursed at one-half the base rate

– The full base code, mileage, and waiting time are reimbursed for the first member only

– For example, no mileage should be billed in conjunction with T2004 - Nonemergency transport; commercial carrier, multi-pass, individualized service provided to more than one patient in the same setting.

– The IHCP does not provide reimbursement for multiple passengers in ambulances or family member vehicles

– Additional reimbursement is not available for multiple passengers when the billing provider does not bill non-IHCP customers for these services


Accompanying Parent or Attendant

– Accompanying parent – When members younger than 18 years of age need an adult to accompany them to a medical service, the provider should bill the appropriate accompanying parent or attendant code

– Accompanying attendant – When adult members need an attendant to travel with them for a medical service, the provider should bill the appropriate accompanying parent or attendant code

– The following are guidelines for billing the accompanying parent or attendant codes: • The procedure code for the base rate and the accompanying parent or attendant is

billed under the IHCP member identification number (RID)• Additional reimbursement is not available for accompanying parent or attendant when

the billing provider does not bill non-IHCP customers for like services • The provider must maintain documentation on the driver’s ticket to support that the

accompanying parent or attendant was transported with the IHCP memberThis documentation must include the name, signature, and relation of the

accompanying parent or attendant


Additional Attendant

– An additional attendant is needed in situations where the driver cannot load the member without help, such as when wheelchair-bound member lives upstairs and the residence has no wheelchair ramp

– The additional attendant who assists must be an employee of the billing provider and is not required to remain for the trip

– Providers must document the need for an additional attendant on the driver’s ticket

– Procedure codes:• A0130 U6 – Nonambulatory transportation; wheelchair van, U6 = additional attendant

• A0424 – Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); requires medical review


Waiting Time

– Waiting time in excess of 30 minutes is reimbursable only when the vehicle is parked outside the medical service provider, awaiting the return of the member to the vehicle and if the member is transported 50 miles or more one-way

– PA must be obtained for all codes associated with trips of 50 miles or more one-way, including waiting time

– The IHCP does not cover the first 30 minutes of waiting time; however, the total waiting time must be included on the claim, or the claim will not be paid appropriately

– One unit of service is billed for each 30 minutes of waiting time (round to nearest unit)

– Documentation, including start and stop times, must be maintained on the driver’s ticket to support the waiting time billed


CollectCopayments


Amounts

Copayment

Copayment Description

$0.50 Services for which the IHCP pays $10.00 or less

$1.00 Services for which the IHCP pays $10.01 to $50.00

$2.00 Services for which the IHCP pays $50.01 or more


Exemptions

Copayment

– Members younger than 18 years old• Package C members are not exempt from copayment requirements

– An assistant or accompanying adult traveling with a member younger than age 18 years old

– Pregnancy indicated in form field 24H

– A place-of-service code indicating a medical institution (for example, acute care hospital, intermediate care facility for the mentally retarded)


InterpretCommon Denials


Mileage is not reimbursable unless the recipient is transported 11 miles or more one way – please verify and resubmit

Edit 4080

– Cause• System is deducting first 10 miles from the claim

– Resolution • The initial 10 miles are included in the base rate; mileage is only reimbursed for 11

miles or more

• Providers should bill the total miles traveled for each trip

• IndianaAIM will automatically calculate the appropriate mileage reimbursement


Possible duplicate

Edit 5000

– Cause• Two round trips made in one day; the second trip denies as a duplicate

– Resolution• Indicate four units on one line in form field 24G for the base code

• Combine total mileage on one line

• Maintain documentation for the two separate round trips


Prior authorization required for one-way trips in excess of 20

Edit 6803

– Cause• Member has already had 20 trips paid

– Resolution• Make sure to check for benefit limits reached on eligibility prior to transporting member

• Submit a PA request for more trips then resubmit claim after approved PA is received


Procedure code is not covered for the dates of service for the program billed – please verify and resubmit

Edit 4021

– Cause• The procedure code billed is not covered for the date of service for the program billed

– Resolution• Verify that the correct procedure code has been billed

• Note: a common cause for this error is billing incorrect modifiers; i.e. destination modifiers with mileage codes (A0425 JN)


No matching pricing segment for the procedure/modifier combination billedEdit 4209

– Cause• The procedure code/modifier combination does not exist on the pricing file

– Resolution• Verify that the correct procedure code has been billed

• Note: a common cause for this error is billing incorrect modifiers; i.e. destination modifiers with mileage codes (A0425 JN)

• NOTE: Error codes 4021 and 4029 will almost always appear together on a denied detail


ClarifyFrequently Asked Questions


Frequently Asked Questions

– Question: Why is the copayment deducted from my claim twice?• Answer: Do not enter copayment amounts in Field 29 of the CMS-1500 claim form.

The IHCP systematically deducts the copayment from the claim payment.

– Question: Why is a copayment deducted when the patient is pregnant?• Answer: To bypass the copayment edit, indicate P in form field 24H of the CMS-1500

claim form.

– Question: Why is a copayment deducted when I transport a patient to the hospital for admission?• Answer: Indicate the appropriate place of service in form field 24B of the CMS-1500

claim form.


Frequently Asked Questions

– Question: Why do I receive denials for the 20-trip limit when I transport a nursing facility patient?• Answer: To bypass the 20-trip limit denial, you must use diagnosis code V70.5 when

transporting a nursing facility patient.

– Question: If I make two trips in one day, why does the second trip deny as a duplicate?• Answer: The IHCP will pay claims for both trips if you bill them on one detail line on the

CMS-1500 claim form. Indicate four units in form field 24G. Maintain documentation for the two separate trips.

– Question: Why are 10 miles of each one-way trip deducted from my mileage? • Answer: The initial 10 miles are built into the base rate. Mileage is only reimbursed for

11 miles or more.


Find HelpResources Available


Helpful Tools

– IHCP Provider Web site at indianamedicaid.com

– IHCP Provider Manual (Web, CD-ROM, or paper)

– IHCP Provider Manual , Chapter 8, Section 4

– Customer Assistance• 1-800-577-1278, or

• (317) 655-3240 in the Indianapolis local area

– Written Correspondence• HP Written Correspondence

P.O. Box 7263Indianapolis, IN 46207-7263

– Provider Relations Field Consultant• Contact information is available on the IHCP

Provider Web site

http://www.indianamedicaid.com/

HP Provider Relations October 2011 Transportation Guidelines.

Documents

Transcript of HP Provider Relations October 2011 Transportation Guidelines.