MLTC Provider Billing Manual - Independence Care … Provider Billing Manual ... 1.1 Welcome to...

MLTC Provider Billing Manual

For Independence Care System’s Medicaid Managed Long-term Care (MLTC) Plan

April 2015

TABLE OF CONTENTS

Section 1: Introduction 1.1 Welcome to Independence Care System

1.2 How To Use This Manual

1.3 Our Care System

Section 2: ICS Operating Procedure 2.1 Coordination of Benefits

2.2 Referrals for Services

Section 3: Claims Processing 3.1 Paper Claims Submissions

3.2 Electronic Claims Submissions & Payer ID

3.3 Claim Appeals

3.4 Payments

3.5 Helpful Hints for Quick Claims Processing

3.6 Common Causes of Delayed Payments

Section 4: Specialty Services Authorization and Billing Guidelines 4.1 Adult Day Health Care

4.2 Audiology

4.3 Dental

4.4 Durable Medical Equipment

4.5 Home Care Aide Services

4.6 Home Delivery of Meals

4.7 Medical Supplies

4.8 Nursing Home Care

4.9 Nutrition Services

4.10 Optometry Services

4.11 Personal Emergency Response System (PERS)

4.12 Podiatry

4.13 Rehabilitation Services

4.14 Respiratory Services

4.15 Skilled Home Health Care Services (RN, LPN, MSW)

4.16 Social Day Care

4.17 Transportation

Section 5: Standard Form Samples 5.1 UB-04 Sample Claim Form

5.2 CMS 1500 Sample Claim Form 5.3 Dental Sample Claim Form

Instructions for ICS Provider Billing – Page 1

April 2015

Section 1: Introduction

1.1 Welcome to Independence Care System

Welcome to Independence Care System! We are happy to have you as part of our Provider

Network.

Independence Care System is a nonprofit organization committed to assisting senior adults and

people with disabilities to live independently in their communities. ICS operates a Medicaid

managed long-term care plan (MLTC) called ICS Community Care and beginning in 2015, a

fully capitated Medicaid and Medicare Plan called Community Care PLUS FIDA-MMP. Our role

in our members’ lives is to coordinate a comprehensive range of health and long-term care

services.

ICS Community Care serves Medicaid-eligible individuals over 18 years of age with physical

disabilities or chronic illness who reside in the Bronx, Brooklyn, Manhattan and Queens. ICS

Community Care PLUS serves adults over 21 years of age who reside in the Bronx, Brooklyn,

Manhattan and Queens.

This Manual is for Community Care/MLTC providers. For a copy of the Provider Manual for

Community Care PLUS FIDA-MMP providers, email [email protected], call Provider

Relations at 646.653.6188, or go to our website at www.icsny.org. You can learn more about ICS

at our website.

1.2 How To Use This Manual

This Manual will serve as your guide to working with ICS. It contains information to help you

understand how the ICS referral for services and billing procedures work. The Manual is

organized in sections that reflect our service categories. We hope this guide is helpful to you and

we welcome feedback on how to improve the guide or our working relationship.

We encourage you to review this material carefully and refer to it when you have a question.

You may also email any questions to our Provider Relations Department at [email protected].

1.3 Our Care System

At Independence Care System, we pride ourselves on member-centered care. Our care system

demonstrates our passion and commitment to our members.

Responsive: What’s important to our members and our member’s family is important to us.

We work with our members—or with our member’s family—to assess their needs for home care,

health care and social services, and to develop their personalized care plan. We ensure that the

plan reflects what they see as their needs, as well as the services that are most crucial to their

health, safety and well-being.

mailto:[email protected]

http://www.icsny.org/

mailto:[email protected]


April 2015

Coordinated: We work with members to get the health care and social services they need.

The ICS team coordinates all of the home care, personal assistance, housekeeping, health care

and social services members need, working with the member’s primary care doctor, physician

specialists, home care agency, and a wide array of community-based providers.

Expert: A highly skilled, dedicated, diverse staff, advocating for the member and with the

member to be as independent as they can be.

Members work with a team of ICS professionals, backed by the resources of our full time staff,

including: Social Workers, Registered Nurses, Multiple Sclerosis-certified and wound-certified

nurses, Medicare and Medicaid eligibility specialists, rehabilitation therapists, wheelchair repair

technicians, transportation managers, and organizers of artistic, educational and social programs

especially for ICS members.

Empowering: Giving the member the knowledge and skills they need to make informed decisions.

Members are at the center of all of the decision-making about their care; they have the final say.

Respectful: A culture of listening and understanding, where members feel they belong.

ICS is at its core a community, made up of our members, their families and caregivers, providers,

and our staff. In coordinating the services our members need, we are committed to nurturing that

sense of community, to ensuring that everyone is treated with respect and that their voices are

heard.

Flexible: When the member’s life changes, so do our services.

The services our members need when they join ICS may not be the same services they need six

weeks, six months, or six years later. Maybe they fell, were hospitalized, landed in a nursing

home, and were terrified that they would never get out. At times like that, ICS is there, making

the changes they need, shepherding them through the transitions they face, getting them back

home.


April 2015

Section 2: ICS Operating Procedures

2.1 Coordination of Benefits

As a Medicaid managed long-term care plan, ICS is the payor of last resort for covered

authorized services. If a service that has been ordered is provided to a member that has other

coverage for that benefit from Medicare and/or other Third Party Health Insurance (TPHI), an

Explanation of Benefit (EOB) or Explanation of Payment (EOP) from that insurer must be

submitted to ICS in order for a provider to receive payments from ICS. Medicare deductibles are

paid in full by ICS. If another insurer has made a payment for service, we will pay co-pays for

covered services according to the rules below:

For most services ICS will pay the difference between the payments from other insurers

and the ICS allowed charge. If payments from other payers equal or exceed the ICS

allowed charge, no payment will be made.

For medical supplies, nursing homes, respirators (i.e., ventilators), eyeglasses and on-

site rehabilitation services, ICS will pay the amount of the Medicare co-pay.

For certified home health agency (CHHA) services there is no co-pay.

The provider is required to maintain, and make available to ICS upon request, records of

coordination of benefits proceeds collected by the provider and amounts paid by third

parties directly to members.

By law, providers are not allowed to charge ICS members for services covered by ICS Medicaid

or Medicare.

2.2 Referrals for Services

All covered services require a written authorization from an ICS care manager, except for urgent,

non-emergency services, which may be provided upon receipt of a verbal referral from the care

manager. Referrals may be for limited duration or may be standing referrals for ongoing care

from a specialist provider. If services are provided without an authorization, payment may be

denied. No member will be referred for services unless he/she is eligible for ICS covered

services. The referral will serve as validation of membership, as well as authorization to provide

services.

The care manager is either a Nurse or a Social Worker who is primarily responsible for

coordinating the health and long-term care services of a member. Each care manager works as

part of a larger unit that includes member services coordinators who provide support to both the

Members and the Care Managers.

Authorization is not a guarantee of payment.


April 2015

Providers who believe that an individual member may need additional or different non-covered

or specialty services from what they are currently receiving should discuss their concerns with

the care management staff. The staff is responsible for assisting members to obtain needed

services even if those services are not covered by ICS.

Providers who are unable to accept a referral must notify the ICS care manager within 48 hours

of receiving the referral, or within 24 hours for skilled nursing home care services.


April 2015

Section 3: Claims Processing

Effective October 1, 2013 Independence Care System has contracted with Productive

Processing Inc. (PPI) to provide claims processing and administrative services. When

submitting claims to PPI, you may submit paper or electronic claims. Submitting electronically

will allow us to process your claims faster and more efficiently.

3.1 Paper Claims Submissions

Mail to:

Independence Care System

c/o Productive Processing Inc.

319 Yard Drive

Verona, WI 53593-8434.

3.2 Electronic Claims Submissions & Payer ID

The ICS Payer ID is: 13396. ICS works with two clearinghouses:

MD Online (preferred)

Phone: 1-888-499-5465 (Option 1)

www.mdon-line.com

Emdeon

www.emdeon.com

Providers can also call the PPI toll free customer service number at: 877.585.1131 for assistance

setting up the submission of EDI claims.

3.3 Claim Appeals

Mail to:

Independence Care System

Attention: Provider Claim Appeals

257 Park Avenue South, 2nd Floor

New York, NY 10010

Appeals must be filed within 30 days of the date of the denial letter.

Determination will be completed within 45 days of the appeal submission.


April 2015

3.4 Payments

Claims and Invoices will be paid within 30 days of receipt for EDI claims and 45 days of receipt

for paper claims, if they meet the following criteria:

Received within 120 days of the date of service, and properly and accurately

completed;

Matches the ICS authorization for services and has the appropriate modifiers; and

Requests the appropriate payment.

All claims received more than 120 days after the date of service will be automatically denied for

untimely filing unless accompanied by an EOB or EOP from another payor.

If ICS requires additional information or documentation, ICS will pay any undisputed portion of

the claim within 45 days and notify the provider of the need for additional information within 30

days of receiving the claim.

Payment rates are based on negotiated rates reflected in the specific ICS/provider contract.

3.5 Helpful Hints for Quick Claims Processing

Providers should bill electronically, if possible.

Claims must include Member Medicaid ID / ICS Member ID.

Providers must include the appropriate CPT/HCPCS codes and modifier on all

submitted claims.

Providers must use the organization name (not individual provider) with the

corresponding Tax ID in Box 33 on the HCFA form and Box 1 on the UB-04 form.

ICS will only pay claims where the Tax ID on the form matches the contracted tax

ID.

3.6 Common Causes of Delayed Payments

HCPCS code and modifier not matching exactly with the authorization

Member Medicaid ID and/or ICS Member ID not included on the form

Untimely submission of claims (after 120 days of DOS)

Individual provider and tax ID used, as opposed to name and tax ID of contracted

organization

In addition, please note that EDI claims are generally processed faster than paper claims.


April 2015

Section 4: Specialty Services Authorization and Billing Guidelines

4.1 Adult Day Health Care

4.1.1 What Is Covered?

Adult day health care (ADHC) provides skilled services such as nursing, physical, speech, and

occupational therapies in a day program setting offered by a residential health care facility or

approved extension site. Other services available in ADHC are: nutritional counseling,

socialization activities, dentistry, podiatry, and administration of medications. Transportation to

and from the facility may be included in the daily rate.

4.1.2 Exclusions

ADHC should not be used for socialization reasons only (please see New York State

Office of the Aging Social Adult Day Care Regulations [9NYCRR 6654.20 Social

Adult Day Care Programs]).

4.1.3 Approval Needed

MD order required

ICS authorization required

4.1.4 Billing

Type of claim form: UB-04 (See page 26)

4.1.5 Fee schedule

Please refer to your ICS contract.

4.2 Audiology

4.2.1 What Is Covered?

Hearing exam

Hearing aid evaluation

Selecting, fitting, dispensing of hearing aids

Hearing aid repair

Replacement of accessories (batteries) when necessary to maintain the hearing aid in

functional order

4.2.2 Exclusions

In-the-canal (ITC) hearing aides that are digital or programmable are not covered.


April 2015


Members can directly access a hearing exam through a network provider. Care managers can

authorize hearing aids and items under $500 in cost that meet the ordering guideline criteria

referenced above and, if a care manager is unsure of the item, it should be reviewed by the care

management supervisor or clinical peer reviewer.

Items costing more than $500 require supervisory review to determine cost effectiveness and

medical necessity. Supervisors will consult with the clinical peer reviewer before a determination

is made.


MD order not required

4.2.4 Billing

Type of claim form: CMS 1500 (See page 27)

For Procedure Codes, Billing Guidelines, and Fee Schedule, please visit:

https://www.emedny.org/ProviderManuals/HearingAid/index.aspx

4.3 Dental

4.3.1 What is Covered?

Routine, preventive dental examination and treatment once every six months such as

examinations / cleaning / gum scaling / x-rays

Restorative care such as fillings / bridgework / dentures

Dentures lost or damaged due to loss, fire, or theft can be replaced with appropriate

documentation.

4.3.2 Exclusions

Dental implants


Member can self-refer to a network provider for routine bi-annual examination and emergent

care. Provider will request authorization for payment of any treatment (routine or non-routine) to

be provided resulting from the examination. Care managers can authorize the cost of the

treatment plan when it is less than $2,000 following the Medicaid fee-for-service coverage

guidelines. If the treatment plan cost is greater than $2,000, the plan must be reviewed by a

licensed dental consultant (prospective peer review) prior to authorization. The dental consultant

will use his/her professional clinical judgment and base his/her decision on generally accepted

professional guidelines.



https://www.emedny.org/ProviderManuals/HearingAid/index.aspx


April 2015

4.3.4 Billing

Type of claim form: ADA Dental Claim Form (See page 28) or CMS 1500.


https://www.emedny.org/ProviderManuals/Dental/index.aspx

4.4 Durable Medical Equipment


Devices and equipment needed in the treatment of a specific medical condition or used to

support functioning in activities of daily living. These include, but are not limited to:

Mobility devices including wheelchairs, walkers, canes, and scooters

Hospital beds

Bathroom equipment

Adaptive aids such as reachers

Repair of the above equipment

4.4.2 Coverage Criteria

Hospital Beds

ICS will cover the lease (rental) or purchase of a hospital bed to be used in a member’s home.

The decision to lease or purchase will be based on other insurance coverage policy, such as

Medicare, and any maintenance agreements with the supplier/manufacturer.

The standard hospital bed covered under the ICS policy is a semi-electric style bed. A semi-

electric bed has power operated controls for adjusting the head position and the foot position.

The height of the bed from the floor is manually adjusted via a hand crank, located at the foot of

the bed.

Hospital beds are 36” wide x 80” long (similar in size to a twin/single bed). Bed extensions are

available to increase the length to 86” long for members who are more than six feet tall.

A fully electric hospital bed has the added feature of power operated control to adjust the overall

height of the bed off the floor and is covered only if the member meets at least one of the

following criteria:

Requires adjustment of the height of the bed from the floor to safely complete

independent transfers;

Member weighs over 350 lbs;**

Member has a caregiver who is elderly or frail; or

Member has tried to use a standard, semi-electric bed and has functional limitations

due to the bed height feature being manually adjustable.

https://www.emedny.org/ProviderManuals/Dental/index.aspx


April 2015

** NOTE: A member who weighs over 350 lbs. will require the use of a bariatric bed.

Bariatric beds are 42” wide (6” wider than standard hospital beds). Because of the increased

weight capacity, the mattress on the bariatric bed is significantly firmer than a standard hospital

bed.

Specialty Mattress and Support Surfaces

ICS will cover payment of specialty mattresses and support surfaces for persons who have or are

at risk for the development of pressure sores. ICS follows the Medicare coverage criteria to

determine the type of support surface to be provided.

Mobility Devices – Ambulatory Aids and Wheelchairs

Mobility aids covered under the Medicare Competitive Bid Program – walkers and standard

manual and power wheelchairs and scooters – may be provided under Medicare guidelines if the

member is dually eligible with Part B Medicare coverage. Claims should be processed via

coordination of benefits.

ICS will provide authorization for an evaluation by a qualified health care provider – an

occupational or physical therapist – to determine the features and function of the mobility device

to best meet the member’s functional need.

ICS coverage policy of all mobility devices follows Medicare guidelines for mobility assistive

equipment (MAE), with the exception of the “in the home use, only” limitation. ICS will cover a

needed mobility device for both/either in home use and/or for community use. If the need for a

wheeled mobility device is only for community use, the claim can be submitted with a GY

modifier (known Medicare denial), along with documentation of a clinical assessment conducted

by a qualified health care provider (i.e., OT, PT).

For a member with complex rehab needs, the provider is encouraged to refer the member back to

ICS for a full seating and mobility assessment by a certified assistive technology professional

(ATP) to generate a recommendation as the result of a clinical assessment of both functional and

environmental needs.

Patient Lifts

ICS will cover payment for the use of a mechanical lift for members who are unable to be safely

transferred using either a stand-pivot method or assisted use of a transfer board. Lifts are either

leased (rented) or purchased depending on primary insurance coverage policy, length of need or

maintenance agreements with the supplier and/or manufacturer.

Members who are unable to safely perform a stand-pivot transfer with the assistance of a

personal care assistant (PCA) or a sliding board transfer will need to use a mechanical lift when

being transferred by a PCA.

The standard mechanical lift as defined by ICS coverage policy is a manually operated, hydraulic

lift with sling. All sling styles and attachment methods available on manually operated lifts will

be covered.


April 2015

A fully electric lift (power operated lifting arm) will be covered if the member meets the one of

the following criteria:

Member weighs over 300 lbs;

Caregiver is frail or elderly; or

A standard lift has been tried and the member has functional limitations due to the

lack of a power operated lifting arm.

For members who have never used a mechanical lift, an in-home physical therapy (PT)

evaluation will be needed to evaluate the member and the environment for the safe use of the lift.

If a lift is recommended, the PT will provide instruction to the PCA and family members on safe

and effective use of the lift.

A one-month rental of a patient lift will be authorized to have a lift available to the PT as part of

the evaluation.


For dually eligible members with Part B coverage, no additional authorization is required from

ICS for a claim demonstrating coordination of benefits with Medicare Part B, requesting

payment of the Medicare 20% co-pay only.

For ICS payment the following is needed:

MD order is required

ICS authorization required – Authorization will be provided following submission of:

o Supplier quote (including pricing following Medicaid fee structure)

o Supporting documentation and justification by a qualified health care professional

that outlines the member’s need for the requested item if the item is not the least

costly alternative item to meet the need 4.4.4 Billing

Type of claim form: CMS 1500


https://www.emedny.org/ProviderManuals/DME/index.aspx



April 2015

4.5 Home Care Aide Services


Home health aides (HHAs) provided as part of a treatment plan administered by a

certified home health agency

Personal care aides (PCAs)

4.5.2 Exclusions

Home care aide hours should not be approved for time a member spends in an adult

day health program or dialysis treatment.


Care manager includes the need for home care aide services on care plan and authorizes the type

and number of hours.

MD order required. Physician certifies the need for service, but does not determine

the number of hours, but may make a recommendation. No MD orders are needed for

housekeeping services.

ICS authorization required. The ICS authorization of hours and dates of service must

exactly match the hours and dates of service rendered by the service provider.

4.5.4 Billing

Type of claim form: UB-04

For Procedure Codes, please refer to the table on the following page:


April 2015

Home Care Procedure Codes Table

ICS Service Provided HCPCS Modifier 1 Modifier 2 Modifier 3 Notes

Home Health Aide S5125

Housekeeper -

Hourly T1019 1A

Housekeeper - One

Time Only T1019 1A 1D

1D Modifier used to distinguish

one time cleaning

Housekeeper - One

Time Only T1019 1A 1D 1J

1D Modifier used to distinguish

one time cleaning

1J Modifier used to distinguish

heavy duty cleaning

Personal Assistant T1019 1B 1B Modifier used to support PA

rate

Personal Assistant -

Mutual T1019 1B 1B Modifier used to support PA

rate


Sleep In T1019 1B

1B Modifier used to support PA

rate


Sleep In Mutual T1019 1B 1M

1B Modifier used to support PA

rate

1M Modifier used to support

reduced (half) daily rate

Personal Care Aide T1019

Personal Care Aide -

Mutual T1019


Sleep In T1019


Sleep In Mutual T1019 1M

1M Modifier used to support

reduced (half) daily rate

Personal Care Aide

BFL Cluster T1019 1I

1I Modifier used to support

different rate (CHCA contract

only)

Please refer to conditions on following page:


April 2015

* Please use hourly rate: Please convert all 15 minute increments into an hourly rate (i.e. If you

are billing one unit, we will process it as one hour, not as a 15 minute increment).

1. All mutual cases shall be billed at the hourly rate multiplied by the number of hours spent

caring for each members

2. All sleep-in cases for dates of service of 5/1/2014 and later will require HCPCS code

T1020 to be billed instead of HCPCS code T1019. The rate billed should be the hourly

rate multiplied by 12 hours. The total amount (hourly rate X 12) should be billed as one

unit.

3. All sleep-in mutual cases for dates of service as of 5/1/2014 and later will require HCPCS

code T1020 to be billed instead of HCPCS code T1019. The rate billed should be the

hourly rate multiplied by six hours. The total amount (hourly rate X six hours per

member) should be billed as one unit.

4.5.5 Home Care Modifier Definitions

Housekeeping 1A

Personal Assistant 1B

One Time Only 1D

Heavy Duty 1J

Sleep in Mutual (1/2 rate) 1M

CHCA Contract Rate

Please Use modifier for

add on dishes

1L

4.5.6 Fee Schedule


4.6 Home Delivery of Meals


Home delivered meals are provided when the need is indicated in a member’s plan of

care.

Members who need assistance with meal preparation (i.e., cannot cook, are not safe

cooking, have no cooking facilities) and have less than four hours per day of home

care service are eligible for one meal per day to be delivered.

Under special circumstances (e.g., PCA is unable to prepare special dietary

requirements to address nutritional changes), a member may receive two (2) meals

daily for a limited time.

4.6.2 Exclusions

None



April 2015



4.6.4 Billing

Type of claim form: Please use CPT code S5170 on a CMS 1500 Form.

Side orders should be billed with modifier (SO).

4.6.5 Fee Schedule


4.7 Medical Supplies


Medical supplies and items for health use other than medications, prosthetic and orthotic devices

and durable medical equipment that are used in the treatment of a specific medical condition and

which are consumable, non-reusable, disposable.

These include but are not limited to:

Diabetic supplies, if not provided by a pharmacy plan

Dressing and other wound care supplies

Urinary catheters

Incontinence supplies (e.g., disposable underwear/briefs/underpads)

Nutritional supplements such as Ensure


As long there is a medical necessity for ordering the supplies referenced they will be ordered.

MD order required


4.7.3 Billing


For Procedure Codes and Billing Guidelines, please visit:




April 2015

4.8 Nursing Home Care


Post-acute care, short-term rehabilitation, respite care, and long-term custodial care in a skilled

nursing facility licensed by the New York State Department of Health.

Nursing home per diem rates cover: Semi-private room and board

Nursing and personal care services, including assistance with all activities of daily

living

Rehabilitation services

Recreational and socialization activities

Maintenance of the member’s room

Other facility-related services

4.8.2 Exclusions

Members who express a preference to be placed in a non-network nursing facility for

a long-term care placement with no intent to return to community living


MD order required (The nursing home will usually get the MD order directly)


4.8.4 Billing

For Procedure Codes, Billing Guidelines, please visit:

https://www.emedny.org/ProviderManuals/ResidentialHealth/PDFS/ResidentialHealth_Billing_

Guidelines_UB04.pdf

4.8.5 Fee Schedule


4.9 Nutrition Services


Assessment by a qualified nutritionist of the nutritional status, food preferences, and

need for therapeutic diets

Nutritional education as part of a treatment plan

4.9.2 Exclusions

None

https://www.emedny.org/ProviderManuals/ResidentialHealth/PDFS/ResidentialHealth_Billing_Guidelines_UB04.pdf

https://www.emedny.org/ProviderManuals/ResidentialHealth/PDFS/ResidentialHealth_Billing_Guidelines_UB04.pdf


April 2015


Members can self-refer for one wellness evaluation per year within the provider network.

Recommended treatment plans submitted by the qualified nutritionist will be authorized by care

manager for members meeting clinical and diagnostic criteria referenced above.



4.9.4 Billing

Type of claim form: UB-04 or CMS 1500

4.9.5 Fee Schedule


4.10 Optometry Services


Optometry services (eye exams, eyeglasses, contact lenses) are covered. This includes:

Annual eye exams to detect visual defects and eye disease

Prescription lenses ($50 per lens) and up to $100 for eyeglass frames every two (2)

years

Replacement of lost, stolen or damaged glasses with documentation

Low vision aids

Low vision services

4.10.2 Exclusions

Members with neurological problems, acute vision loss, elevated IOP, suspicious optic

nerves, diabetic retinopathy or cataracts, should be referred to an ophthalmologist.

Contact lenses and tinted lenses are not covered when prescribed for cosmetic

reasons only.


Members can self-refer for exam from a network provider. Items and services under $500 are

authorized following Medicaid fee-for-service guidelines. Items greater than $500 require

supervisor’s review and any recommendation to deny is reviewed by a clinical peer reviewer

utilizing professional clinical judgment and low vision standards of care.




April 2015

4.10.4 Billing


For Procedure Codes and Billing Guidelines, please visit:

https://www.emedny.org/ProviderManuals/VisionCare/index.aspx

4.11 Personal Emergency Response System (PERS)


An electronic device worn by a member to secure help in the event of a physical, emotional, or

environmental emergency. This includes:

Installation of equipment

Monitoring of equipment

Console unit, two personal care activators, and a smoke detector

4.11.2 Exclusions

Member is no longer living at home (e.g., nursing home, transitional housing)

Members who receive 24-hour care or have a reliable caregiver present in home

Members who have shown significant improvement in condition and no longer need

PERS


MD order required


4.11.4 Billing



https://www.emedny.org/ProviderManuals/PERS/index.aspx

4.11.5 Fee Schedule


https://www.emedny.org/ProviderManuals/VisionCare/index.aspx


April 2015

4.12 Podiatry


Routine foot care, such as treatment of corns and calluses, trimming of nails, hygienic

care such as soaking or cleaning feet

Non-routine care such as: 1. Diagnosis and treatment of any illness or injury in the foot, such as infection or

fungus

2. Incisions

3. Excisions

4. Removal of foreign objects

5. Repair or suture of tendons, foot, flexor

6. Treatment of dislocations

4.12.2 Exclusions

None




4.12.4 Billing



https://www.emedny.org/ProviderManuals/Podiatry/index.aspx

4.13 Rehabilitation Services


Rehabilitation services include physical, occupational, and speech therapies provided in a

licensed rehabilitation facility or through a certified home health agency.

Physical therapy services include examination, diagnosis, and treatment of

musculoskeletal and neuromuscular impairments resulting in functional limitations.

Occupational therapy includes evaluation of performance, skills assessment, and

treatment customized to improve ability to perform activities of daily living.

Speech therapy includes evaluation and treatment of slurred speech, breath control,

voice issues, aphasia, stuttering, swallowing difficulties and augmentative

communication needs.


April 2015


Network therapists will submit recommended treatment plans for peer review and approval for

the authorization. The member’s care management coordinator (CMC), who supports the

member’s assigned team, will forward any recommendation for approval for authorization to a

clinical peer reviewer for a decision based on professional clinical judgment and professional

standards of care.

MD order required


NOTE: Network providers are encouraged to call ICS 1-877-ICS-2525 (877-427-2525) and

request to speak to the CMC supporting the member’s assigned team to determine if the member

has recently received services from another provider within the calendar year, prior to drafting

a treatment plan that may not be authorized.

4.13.3 Billing



https://www.emedny.org/ProviderManuals/RehabilitationSrvcs/index.aspx

4.13.4 Fee Schedule


4.14 Respiratory Services


The performance of preventive, maintenance and rehabilitative airway-related techniques and

procedures. Includes:

Application of medical gases

Humidity and aerosols

Intermittent positive pressure

Continuous artificial ventilation

Administration of drugs through inhalation and related airway management

Patient care

Patient teaching

4.14.2 Exclusions

None


April 2015


All MD orders for respiratory services are followed and implemented. Care manager

authorization of equipment as part of care plan; service component is part of contractual

agreement with equipment provider.


MD order required

4.14.4 Billing


4.14.5 Fee Schedule


4.15 Skilled Home Health Care Services (Skilled RN, LPN, MSW Services)


Home health care includes skilled services that are of a preventive, therapeutic, or health

teaching nature. This includes: Skilled nursing services

Medical social services

Home infusion (chemotherapy, intravenous feedings)

Skilled nursing includes both registered (RN) and licensed practical nursing (LPN) care arranged

(by contract) through certified home health agencies, licensed agencies, or nursing registries.

Medical social services describe the psychosocial assessment and treatment planning offered by

qualified social workers and social work assistants.

4.15.2 Exclusions

None


MD order required (Certified home health agency will obtain MD orders separately.)


4.15.4 Billing


4.15.5 Fee Schedule


April 2015


4.16 Social Day Care


Social day programs provide special recreational and therapeutic activities designed to provide

socialization. Service highlights include: Arts and crafts

Physical activities

Music and singing

Cooking

Discussion groups

Parties and holiday events

Diverse cultural programs

Snacks and lunch

4.16.2 Exclusions

None




4.16.4 Billing


4.16.5 Fee Schedule


4.17 Transportation


Non-emergency transportation (e.g., public transportation, Access-A-Ride, car service,

ambulette, or ambulance) to medical appointments or adult or social day program activities that

are part of the member’s care plan.

4.17.2 Exclusions

Transportation to non-medical appointments that are not authorized by care management

as part of the care plan.


April 2015


Once level of transportation is authorized by care manager, members can arrange

transportation to medical or day program appointments directly or via the Member

Services Center.


4.17.4 Billing

Type of claim form: CMS 1500 only

For procedure codes and billing guidelines please visit

https://www.emedny.org/ProviderManuals/Transportation/index.aspx

For Transportation Codes with HCPCS/modifiers, please refer to the table on the following page.

4.17.5 Fee Schedule



April 2015

Transportation Codes with HCPCS / Modifiers

Service Code: Ambulette

HCPCS Code HCPCS

Code HCPCS Code

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

T2003 T2003 T2003

Service Code: Ambulance with Basic Life Support

HCPCS Code HCPCS

Code HCPCS Code

A0428 A0428 A0428

A0428 A0428 A0428

A0428 A0428 A0428

A0428 A0428 A0428

A0428 A0428 A0428

A0428 A0428 A0428

Service Code: Ambulance with Advanced Life Support

HCPCS Code HCPCS

Code HCPCS Code

A0426 A0426 A0426

A0426 A0426 A0426

A0426 A0426 A0426

A0426 A0426 A0426

A0426 A0426 A0426

A0426 A0426 A0426

Service Code: Livery

HCPCS Code HCPCS

Code HCPCS Code

A0100 A0100 A0100

A0100 A0100 A0100

A0100 A0100 A0100

For detailed instructions, please refer to

https://www.emedny.org/ProviderManuals/Transportation/PDFS/Transportation_Billing_Guideli

nes.pdf.

https://www.emedny.org/ProviderManuals/Transportation/PDFS/Transportation_Billing_Guidelines.pdf

https://www.emedny.org/ProviderManuals/Transportation/PDFS/Transportation_Billing_Guidelines.pdf


April 2015

Section 5: Standard Form Samples

5.1 UB-04 Sample Claim Form


April 2015

5.2 CMS 1500 Sample Claim Form


April 2015

5.3 Dental Sample Claim Form

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