Service provided by excluded, opt out physician - denial

Services provided by a Medicare sanctioned/excluded provider. No Medicare payment may be made.


Opt-Out physicians and practitioners:

Medicare payment may be made for the claims submitted by a beneficiary for the services of an opt out physician or practitioner when the physician or practitioner did not privately contract with the beneficiary for services that were not emergency care services or urgent care services and that were furnished no later than 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare (see 42 C.F.R. 405.435(c)). Therefore, if the beneficiary submits a claim for a service that was furnished by an opt out physician or practitioner, then the carrier must contact the opt out physician or practitioner in order to ascertain whether the beneficiary entered into a private contract with the opt out physician or practitioner. (Note: The carrier should obtain a copy of the private contract from the opt out physician/practitioner before denying the beneficiary’s claim if the beneficiary did, in fact, enter into a private contract with the physician or practitioner.) If the beneficiary did not enter into a private contract with the physician or practitioner and the beneficiary did not receive notice from the carrier that the physician opted out of Medicare, then Medicare payment may be made to the beneficiary for the non-emergency and/or non-urgent care services (assuming that the services would otherwise be payable). On the other hand, if the beneficiary did enter into a private contract with the physician or practitioner for the services or received services from the physician/practitioner 15 days after the date of a notice by the carrier that the physician or practitioner has opted out of Medicare, then no Medicare payment may be made. Medicare has instructed opt out physicians and practitioners that private contract language must include beneficiary instruction precluding the beneficiary from billing Medicare for these services. An example of language that may be considered:


Claim denied because services were provided by an Opt-Out physician or practitioner. No Medicare payment may be made.



Contractors shall maintain documentation of beneficiary complaints involving violations of the mandatory claims submission policy and a list of the top 50 violators, by State, of the mandatory claim submission policy.

Contractors are encouraged to educate providers and suppliers that they must be enrolled in the Medicare program before they submit claims for services furnished or supplied to any Medicare beneficiary.

The above policy, including the NPI requirement, is not applicable for foreign beneficiary claims submitted for covered services. These claims should be processed using guidelines for foreign claims.

The above policy, including the NPI requirement, is not applicable to beneficiary claims submitted to DMEMACs for durable medical equipment, prosthetics, orthotics, and supplies. These claims should be processed by DMEMACs using current procedures.

M25, M26, M27 and 54 - Co surgeon denial codes

Beneficiary Liability on Denied Claims for Assistant, Co- surgeon and Team Surgeons

MSN message 23.10 which states “Medicare does not pay for a surgical assistant for this kind of surgery,” was established for denial of claims for assistant surgeons. Where such payment is denied because the procedure is subject to the statutory restriction against payment for assistants-at-surgery. Carriers include the following statement in the MSN:

"You cannot be charged for this service.” (Unnumbered add-on message.)

Carriers use Group Code CO on the remittance advice to the physician to signify that the beneficiary may not be billed for the denied service and that the physician could be subject to penalties if a bill is issued to the beneficiary.

If Field 23 of the MFSDB contains an indicator of “0” or “1” (assistant-at-surgery may not be paid) for procedures CMS has determined that an assistant surgeon is not generally medically necessary.

For those procedures with an indicator of “0,” the limitation on liability provisions described in Chapter 30 apply to assigned claims. Therefore, carriers include the appropriate limitation of liability language from Chapter 21. For unassigned claims, apply the rules in the Program Integrity Manual concerning denial for medical necessity.

Where payment may not be made for a co- or team surgeon, use the following MSN message (MSN message number 15.13):

Medicare does not pay for team surgeons for this procedure.

Where payment may not be made for a two surgeons, use the following MSN message (MSN message number 15.12):

Medicare does not pay for two surgeons for this procedure.

Also see limitation of liability remittance notice REF remark codes M25, M26, and M27.

Use the following message on the remittance notice:

Multiple physicians/assistants are not covered in this case. (Reason code 54.)

What is Livanta and QIO - HOW TO APPEAL TO IT

Livanta

Livanta is responsible for the quality of care review of services provided to Massachusetts Medicare patients enrolled in Medicare Advantage products with CMS. This includes Tufts Medicare Preferred HMO members.

The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, as amended by the Omnibus Budget Reconciliation Act (OBRA) of 1986, requires Tufts Health Plan to participate in an external review of its QI program for members enrolled in Tufts Medicare Preferred HMO. The responsibilities of each organization that conducts the external review of the Tufts Medicare Preferred HMO plan are delineated in the Tufts Health Plan/Livanta agreement.

The Livanta Bene ciary and Family Centered Care Quality Improvement Organization (BFCC-QIO) handles all Medicare bene ciary complaints, quality of care reviews, medical necessity reviews, and discharge appeals from hospitals, skilled nursing facilities, home health and hospice providers, and rehabilitation facilities. Medicare patients have certain rights and protections, and Livanta is here to help.

Livanta is the new Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Medicare case review. Livanta handles all appeals and quality of care complaints for people on Medicare who live in Massachusetts.

Livanta is Your QIO for Case Review


WHAT IS LIVANTA?

Livanta is a company that helps its customers by providing services like consulting in health care, program integrity, health technology and information, quality improvement, business process and outsourcing and strategic solutions for communications in the public sector and for health care consumers. The company helps store, protect and analyze large volumes of sensitive records of health care data of the American people to help the healthcare system function with proper integrity.


APPEAL FOR CLAIM

Livanta appeal can be made if a beneficiary thinks that his or her Medicare services are coming to an end too soon. For example, if the patient is told that his or her nursing home is discharging him or her, but the patient does not feel healthy enough for leaving. If the individual wishes to file an appeal regarding the situation, one can contact on the Livanta appeal phone number. The appeal usually relates to any request for review and one can contact the Livanta appeal address, process, phone number and they will provide quality and beneficent medical cover for the case reviews and also appropriate if the health services provided to the individual are according to the professional recognized care standards defined.

Appeals

• An appeal can be led if you think your Medicare services are ending too soon.

For example, you are told the nursing home is discharging you, but you do not feel  healthy enough to leave.

• If you wish to le an appeal, call Livanta at 1-866-815-5440.

** An appeal relates to a request for review (for example, you are told the nursing home is discharging you and will no longer cover your stay, but you do not feel healthy enough to leave)

** If you wish to file an appeal, call Livanta at 866-815-5440 and select Option 1


Complaints

• A complaint relates to a concern about the quality of care or other services you get from  a Medicare provider. For example, you developed a hospital-acquired infection and did  not receive treatment.

• If you wish to le a complaint, call Livanta at 1-866-815-5440.


• You will need to complete a Medicare Quality of Complaint Form found at:

 www.bfccqioarea1.com/states/ct.html.
 You may mail the form to: BFCC-QIO Program, Area 1
 9090 Junction Dr., Suite 10
 Annapolis Junction, MD 20701


• Hours for Complaints: Monday - Friday: 9:00 a.m. - 5:00 p.m. (local time)
 Hours for Appeals: Monday - Friday: 9:00 a.m. - 5:00 p.m. (local time)
 Weekends - Holidays: 11:00 a.m. - 3:00 p.m. (local time)
 24 hour voicemail service is available

Livanta appeal address

Helpful Tips

Have the following information

handy when you call:
** Medicare card
** Medicare number
** Address and phone number
** Date of birth
** Date of service
** Full name and contact information of the facility or healthcare provider


Billing

Livanta is not responsible for Medicare billing. If you have questions regarding your bill, please call 1-800-MEDICARE

FILING OF COMPLAINTS

A complaint is filed that relates to concerns about the quality and hospitality of care and any other service received from the Medicare provider. A good example would be developing an infection or disease in hospital and not receiving treatment for it. To file a complaint one can approach Livanta and rest assured all your services will be taken care of. One can also check their Livanta appeal status and can also file Livanta second appeal if the individual feels his or her service was not properly addressed during the first appeal.

To file a complaint, one must complete the Medicare Quality of Complaint Form that can be found on their website and this must be mailed to the concerned company for further checking of the claim or appeal. Most companies have specific hours for filing of appeals or complaints, but provide a 24 hour round the clock, voicemail service for the benefit of the people.

TIPS TO BE TAKEN CARE OF 

The individual must possess the mentioned information at hand when he or she calls to file an appeal or complaint like the Medicare card, Medicare number, personal address and phone number, date of birth, date of the service, full name along with contact information of the concerned health care provider or facility. Livanta will not be responsible for the Medicare billing and for queries regarding the billing one can call the helpline number mentioned online.


Livanta also maintains a good review system that ensures that the services provided to the Medicare beneficiaries who are enrolled in various health plans in Medicare are of sufficient quality across all the settings. The review system of Livanta addresses issues like appropriateness of the treatment, accessibility to various services, timeliness of the provided services, potential for the under-utilization of the services, potential for the premature discharge of the patient etc.

LIVANTA APPEAL STATUS

One can check their Livanta appeal status by calling the Livanta appeal phone number which is the Livanta Medicare helpline 1877-588-1123. To check the status of Short Stay Reviews one must call at 1866-603-0970. The Livanta second appeal can also be checked by calling on the mentioned helpline numbers.

 

Livanta Reviews

Livanta maintains a review system to ensure that services provided to Medicare beneficiaries enrolled in Medicare health plans are of adequate quality across all settings. This review system addresses the following issues:

** Appropriateness of treatment

** Potential for under-utilization of services

** Accessibility to services

** Potential for premature discharge of patients

** Timeliness of services provided

** Appropriateness of the setting for the provision of services

** Appropriateness of the Medicare health plan’s activities to coordinate care, such as the adequacy of discharge planning and follow-up of abnormal diagnostic studies
Livanta will notify Tufts Health Plan Medicare Preferred regarding issues that include results of Livanta’s review activities, unless otherwise specified in the Livanta/CMS contract. These issues will be identified as Quality of Care concerns or documentation concerns.

Tufts Health Plan Medicare Preferred will be notified when a Livanta review indicates a quality problem regarding an out-of-plan emergency or urgently needed care that an out-of-plan hospital, skilled nursing facility (SNF), or other health care facility provided to a Tufts Medicare Preferred HMO member, and the problem is attributable to the institution. However, the quality problem identified with respect to these services will be attributed to the out-of-plan provider/practitioner, rather than to Tufts Health Plan Medicare Preferred.

Quality Improvement Organization Complaint Process

For Tufts Medicare Preferred HMO members concerned about the quality of the care received can also file a complaint with Livanta at 866.815.5440. Quality Improvement Organizations (QIO), such as Livanta, are groups of doctors and health professionals that monitor the quality of care provided to Medicare beneficiaries. Livanta Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Massachusetts. The Livanta review process is designed to help prevent any improper practices. This process is separate and distinct from the Tufts Medicare Preferred HMO grievance (complaint) process.

The QIO is under contract to the CMS to conduct medical reviews and other functions with respect to Medicare beneficiaries.

Member Grievance Procedure

Per regulatory guidelines and as part of the Tufts Health Plan commitment to ensuring member satisfaction, we have established a forum for members or authorized representatives to express concerns regarding their experiences with health care providers. The member grievance procedure, allows for the documentation and review of member complaints, as follows:

1. Upon receipt of a verbal or written complaint, the grievance specialist acknowledges either verbally or in writing that the complaint was received and will be reviewed within 30 calendar days or within 24 hours if the grievance is expedited. All grievances pertaining to clinical care and/or services issues are reviewed within the Clinical Quality Improvement (CQI) department. All grievances pertaining to provider billing, along with operations and activities of the Plan are reviewed within the Appeals and Grievances (A&G) department. The CQI and A&G department can accept any information or evidence concerning the grievance orally or in writing.

2. In most instances, providers or their office managers (depending on the specific situation) are notified either verbally or in writing about the complaint and asked for input.

3. If the complaint pertains to a quality of care issue (clinical grievance), the clinical review team evaluates the information. The grievance is assigned a rating for degree of severity and preventability of the issue of concern. The provider is generally notified of the results of the review. All grievances and their respective ratings are entered into our secured quality database for tracking and trending purposes. This data becomes part of the provider’s credentialing file and is reviewed periodically.
It is the member’s responsibility to notify Tufts Health Plan Medicare Preferred of concerns about his/her health care services. It is the responsibility of all network providers to participate in our grievance review process.

Providers are expected to respond to a request for information within five business days, as it is standard for providers to respond to the plan’s request for information in investigating member grievances. This turnaround time is required to ensure that the plan meets its regulatory and accreditation requirements to the member and remains compliant with all state and federal (CMS) requirements.

What is Member Grievances

Member Grievances

Members have the right to file a complaint if they have concerns or problems related to their coverage or care. Appeals and grievances are two different types of member complaints.

** A Part C grievance is any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame.

 ** In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.

 ** A Part D grievance is any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D plan sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item.

Tufts Medicare Preferred HMO and its network providers must not treat members unfairly or discriminate against them because they initiate a complaint.

CLIA Certification Number Required MA 120, MA 130

Remark Code/ Message Number

• MA120: Missing/incomplete/invalid CLIA certification number
• MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

Resolution 
• Entities that perform clinical laboratory tests must obtain certification through the state department of health. This is known as Clinical Laboratory Improvement Amendments of 1998 (CLIA) certification.
• Your CLIA number must be submitted on claims for clinical laboratory tests, including tests that are classified as 'CLIA-waived.' Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.
o Some clinical laboratory tests must also be submitted with HCPCS modifier QW. The Food and Drug Administration (FDA) determines which laboratory tests are waived. Please note that not all CLIA-waived tests require HCPCS modifier QW.
• Determine if the CPT code is a waived test by accessing the Centers for Medicare & Medicaid (CMS) CLIA Web page
• Palmetto GBA will publish information on tests newly classified as 'waived' on our website
• Submit your corrected claim as a new claim. Claims that are missing required CLIA certification numbers are rejected as 'billing errors' and must be submitted as new claims.

CLIA Background

• CMS regulates laboratory testing through CLIA. The primary objective of the CLIA program is to ensure quality laboratory testing. CLIA regulations require facilities to be appropriately certified for each test they perform.

• CLIA requires all facilities that perform even one test, including waived tests, on materials derived from the human body for the purpose of providing information for the diagnosis, prevention or treatment of any disease or impairment of, or the assessment of the health of human beings to meet certain Federal requirements

• Any facility that performs tests for these purposes, including physician office laboratories, are considered laboratories under CLIA and must apply for and obtain a certificate from the CLIA program

• New waived tests are approved by the FDA on a flow basis, and the tests are valid as soon as they are approved

• Generally, CLIA certification is required for each location where testing is performed. There are exceptions for laboratories that are not at a fixed location and laboratories within a hospital.

Medicare rejection CO 24 - covered by Advantage plan

 We received a RUC for the claim adjustment reason code (CARC) CO24. What steps can we take to avoid this RUC code?

Charges are covered under a capitation agreement/managed care plan.

A: You are receiving this reason code due to the beneficiary being enrolled in a Medicare Advantage (MA) plan or covered under a capitation agreement.

Medicare Advantage (MA):

• If a Medicare beneficiary enrolls into a Medicare Advantage plan, that health plan will then replace the beneficiary’s traditional Medicare plan.

• Medicare claims must be submitted to the MA plan.

• If a claim is submitted to Medicare it will be returned as an unprocessable claim, and the remittance advice (RA) will indicate this claim adjustment reason code CO24.

• Obtain eligibility and benefit information prior to rendering services to patients.

• Ask patients if they have recently enrolled in any new health insurance plans.

• Request to see a copy of all of their health insurance cards.

• Always remember to check beneficiary eligibility prior to submitting claims to Medicare.

• Click here for ways to verify the beneficiary's eligibility prior to submitting claims to First Coast.
• If the beneficiary's record with CMS is updated to reflect they were not enrolled in an MA plan on the date(s) of service in question, resubmit the claim to First Coast Service Options Inc. (First Coast).

• Claims that are returned as unprocessable cannot be appealed, for more information click here.
End-stage renal disease (ESRD) capitation agreement:

• Prior to seeing a patient for ESRD related dialysis, ensure they are not covered under a capitation agreement with another provider. If they are, contact the capitation provider before rendering the service.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ESRDpayment/index.html

• ESRD-related capitation agreements -- If the service(s) should be considered outside of the capitation agreement, please follow the ESRD claim guidelines external link and correct the claim with the appropriate modifiers. Resubmit the corrected claim for payment.




Medicare replacement FAQ

Q: For a patient not enrolled in traditional Medicare Part B but enrolled in a Medicare replacement, can a participating Part B provider ask for payment at the time of service (at the standard Medicare fee schedule rate) and instruct the patient to file the claim with the Medicare replacement for direct reimbursement? Regarding traditional Medicare vs. Medicare Advantage (MA) plans, what fee schedule can we bill?

A: If the patient is enrolled in a Medicare Advantage (MA) plan, contact the MA prior to rendering services to determine what amount he or she is responsible for paying out of pocket. This information will provide you with guidance on whether to treat and/or bill the patient. Medicare does, however, limit the amount providers can bill patients for services. For more information, please refer to Medicare & You 2018 external pdf file.

When a patient enrolled in a MA plan uses out-of-network providers, their out of pocket expenses for covered services may be higher. It is important to verify with the patient [and confirm through First Coast’s Part B Interactive Voice Response (IVR) system at 1-877-847-4992 or through SPOT (Secure Provider Online Tool)] if the patient is enrolled in an MA.

The Centers for Medicare & Medicaid Services (CMS) internet-only manual (IOM) Publication 100-16, Services of non-contracting providers and suppliers, Chapter 4 - Benefits and Beneficiary Protections external pdf file states:

• MA plans must reimburse non-participating providers for emergency care, ambulance services sought through 911 calls, and for medically necessary dialysis services from a non-participating provider when the patient is out of the service area.

The CMS IOM Publication 100-16, Services of non-contracting providers and suppliers, Chapter 6 - Relationships with Providers external pdf file further states:
• Non contracted providers must accept as payment in full no amount greater than what original Medicare would pay and cannot bill the patient more than their normal cost-sharing amounts (coinsurance).

There are numerous potential scenarios and the answer may change dependent upon terms of the plan. In general, if an MA enrollee seeks care outside of the MA plan in which he/she is enrolled and the Medicare Advantage organization (MAO) sponsoring the MA plan has no legal liability for reimbursement, then yes, the provider can bill the MA enrollee. The provider should not bill the MA enrollee more than the original Medicare amount for what would otherwise be covered A/B services.
There is no specific guidance for collecting payment from the patient at the time services are rendered.

CLIA related denials – CO-B7 This provider was not certified/eligible to be paid for this procedure/service on this date of service & CO-18 – Duplicate service

CLIA: Laboratory Tests

Denial Reason, Reason/Remark Code(s): 

• CO-B7: This provider was not certified/eligible to be paid for this procedure/service on this date of service
• CPT codes include 82947 and 85610


Resolution 

• HCPCS modifier QW must be submitted with certain clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) determines which laboratory tests are waived.
• Note: Not all CLIA-waived tests require HCPCS modifier QW
• Determine if the CPT code is a waived test by accessing the CMS CLIA Web page
• Palmetto GBA will publish information on tests newly classified as 'waived' on our website. Please note, the list of CLIA-waived procedures is updated as often as quarterly.
• The CLIA certificate number is also required on claims for CLIA waived tests. Submit this information in Loop 2300 or 2400, REF/X4, 02 for electronic claims. For paper claims, submit the CLIA certification number in Item 23 of the CMS-1500 claim form.
• Access complete instructions for correctly submitting HCPCS modifier QW in the Palmetto GBA Modifier Lookup tool.

Clinical Laboratory Procedures: Duplicate Denials

Denial Reason, Reason/Remark Code(s) 
• CO-18 - Duplicate Service(s): Same service submitted for the same patient
• CPT codes: 36415, 80048, 80053, 80061, 83036, 84443, 85610

Resolution/Resources
First: Verify the status of your claim before resubmitting. Use the Palmetto GBA Online Provider Services (OPS) tool or call the Palmetto GBA Interactive Voice Response (IVR) unit.
• All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
• Access the introductory article to learn more by selecting the 'Introducing Online Provider Services' graphic on the top of any of our main contract Web pages
• Please note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
• Billing services and clearinghouses should contact their provider clients to gain access to the system
• Specific instructions for accessing claim status information through OPS are available in the OPS User Manual
CPT modifier 91 may be submitted to identify an identical laboratory test for the same patient on the same date.
• This modifier may not be submitted when tests are rerun to confirm initial results due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required
• This modifier may not be used when other codes describe a series of test results (e.g., glucose tolerance tests)
• For clinical laboratory tests ordered by an ESRD facility: these tests must be submitted with CPT modifier 91 if any single service (same CPT code) is ordered for the same patient, and the specimen is collected more than once in a single day, and the service is medically necessary
o CPT modifier 91 must be submitted with services that meet these criteria, regardless of whether the test is also submitted with HCPCS modifiers CD, CE or EF
o Any line item on a claim that meets these criteria and is submitted with CPT modifier 91 will be included into the calculation of the 50/50 rule
o After calculation of the 50/50 rule, services used to determine the payment amount may not exceed 22

Reviewing DX with PCP which was denied for pre - exisiting

Practice address

Phone# 407-123-45678
______________________________________________________________________________________
05/28/2010
Dr.
Attn: Ayse
Address here
FL 33713-8723
Re: Request to re-view the diagnosis codes whether falls under pre-existing period.

Patient Name :
Primary Carrier : BCBS
Health Insurer Identification Number : HOSPH41862466

Dear Sir/Madam:
This is to bring to your kind attention that BCBS denied the above mentioned patient’s claims for pre-existing condition information hence we would like to request you to review the diagnosis codes mentioned below in order to determine if any of these codes fall under the waiting period.
The diagnoses are:
491.20, 518.82, 786.52, 511.9, 486, 510.9, 496, 510.9, 786.09, and 780.53……..
Thank you for reviewing and assisting us in reversal of this claim denial. If you require any
additional Information, please contact me at 407-745-1849 between the hours of 8:00 a.m and 5:00 p.m.

Sincerely,
Henry Samuel
(Account Receivable – Reimbursement Specialist)

Provider appeal letter when payment made to facility

Practice address

PO BOX 123
Kenneth City FL1234
Phone#123-456-789
_______________________________________________________________________
05/10/2010

Careplus
Attn: Medical Records Department
4925, Independence Parkway Suite 300
Tampa, FL, 33634


Re: Appeal of Medical Claim
Patient Name: 
Health Insurer Identification Number: 9958002012111
Claim Number: 911204441611
Call Reference Number: 91111365797111
Service Date: 10/13/2009


Dear Sir/Madam:

We are appealing your decision and requesting reconsideration of the attached claim that was denied on 12/08/2009 as "Global payment made to Facility for this service. Seek reimbursement for professional fees from facility appropriately."

We feel these charges should be allowed for the following reason(s):

• Dr.X  is the only Physician who interpreted the service (Professional component only) performed at  Outpatient Hospital on  10/13/2009. Hence Dr.X is due and eligible to get paid for the professional
services that he had rendered.

•  Hospital has billed Careplus for a global procedure in error. This facility only performed the technical component.

Now we are requesting you to reconsider our claim, reverse the payment of professional component from the other group and reimburse Dr. for the same.

When we had a discussion with the Careplus customer service, the representative advised us to file an appeal with supporting medical documents. Herewith I have attached the Claim form, Dr. X Intrepretation document and Careplus EOB.

Thank you for reviewing and reversing this claim denial. If you require any additional information, please contact me at 407-123-4567 between the hours of 8:00 a.m-5:00 p.m.

Sincerely,

(Account Receivable – Reimbursement Specialist)

Appeal letter to process the out of network claim when treated on emergency

Practice address
Po box 1234
Kenneth City FL-123456

Georgia Medicaid
Attn: Claims Department
PO Box: 7000
McRae, GA- 31055

Re: Out of state Medical Claim
Patient Name:
Insured’s Identification Number: 11107639099123
Service Date: 06/26/2010 to 07/02/2010
Call Reference#: 972217511

Dear Sir/Madam,

This is to report a claim for a service rendered in out of network state Florida. Patient was admitted in  Hospital on 06/25/2010 with acute respiratory failure which required urgent care and was referred to Dr  for an intensive consultation on 06/26/2010 and for further review till 07/02/2010. Hence we would like to request you to take the above situation into consideration and have the claims reimbursed at the earliest possible.

Herewith all supporting Medical documents are attached.

Incase of any queries or clarifications please call (407)123-4569 between 8.00 AM and 5.00 PM Monday through Friday Eastern Time.


Sincerely,

(Account Receivable- Reimbursement Specialist)


Reimbursement for OUT OF STATE/BEYOND BORDERLAND PROVIDERS

Reimbursement for services rendered to beneficiaries is normally limited to Medicaid-enrolled providers. MDHHS reimburses out of state providers who are beyond the borderland area (defined below) if the service meets one of the following criteria:

** Emergency services as defined by the federal Emergency Medical Treatment an  Active Labor Act (EMTALA) and the Balanced Budget Act of 1997 and its regulations; or

** Medicare and/or private insurance has paid a portion of the service and the provider is billing MDHHS for the coinsurance and/or deductible amounts; or

** The service is prior authorized by MDHHS. MDHHS will only prior authorize non-emergency services to out of state/beyond borderland providers if the service is not available within the state of Michigan and borderland areas.

Note for Hospice Providers: An out-of-state/borderland hospice provider cannot cross over the border into Michigan to provide services to a Medicaid beneficiary unless:

** The agency is licensed and Medicare-certified as a hospice in Michigan; or

** The state in which the provider is licensed and certified has a reciprocal licensing agreement with the State of Michigan.

If one of these conditions is met and the hospice provides services across state lines, its personnel must be qualified (e.g., licensed) to practice in Michigan.

Medicaid will not cover services for a beneficiary who enters a hospice-owned residence outside of Michigan. The Community Health Automated Medicaid Processing System (CHAMPS) will not recognize the core-based statistical area (CBSA) code of another state. Additionally, when a Michigan Medicaid beneficiary voluntarily enters a hospice-owned residence in another state to receive routine hospice care, they are no longer considered a Michigan resident and, therefore, are not eligible for hospice benefits under Michigan Medicaid.

Note for Home Health Providers: An out-of-state/borderland home health provider cannot cross over the border into Michigan to provide services to a Medicaid beneficiary unless they are Medicare certified as a home health agency in Michigan. If this condition is met, and the home health agency provides services across state lines, its personnel must be qualified (e.g., licensed) to practice in Michigan.

Note for Nursing Facilities: The only borderland nursing facilities that are allowed to enroll with Michigan Medicaid are those facilities where Michigan beneficiaries were admitted to the facilities prior to October 1, 2007 or were admitted where placement was approved by Medicaid due to closure of a Michigan facility. To ensure that these borderland nursing facilities serving Michigan Medicaid beneficiaries have a current standard Health Survey, a Life Safety Code Survey, and a current facility license, MDHHS requires this information be sent to MDHHS each year. The review of survey and license information by MDHHS will occur prior to December 31 of each year. This information must be received by the Medicaid Provider Enrollment Unit by November 1 of each year so the borderland nursing facility Medicaid enrollment continues. (Refer to the Directory Appendix for contact information.)

Managed Care Plans follow their own Prior Authorization criteria for out of network/out of state services. Providers must be licensed and/or certified by the appropriate standard-setting authority. All providers rendering services to Michigan Medicaid beneficiaries must complete the on-line application process described in the Provider Enrollment Section of this Chapter in order to receive reimbursement.

Exceptions to this requirement may be made in special circumstances. These circumstances will be addressed through the Prior Authorization process.


Out of state/beyond borderland providers enrolled with the Michigan Medicaid program may submit their claims directly to CHAMPS. Providers should refer to the appropriate Billing and Reimbursement chapter of this manual for billing instructions.

MDHHS is prohibited by federal law from issuing Medicaid payment to any financial institution or entity whose address is outside of the United States.

Out of state/beyond borderland providers have a responsibility to follow Michigan Medicaid policies, including obtaining PA for those services that require PA.

cpt code 15002, 15003, 15004, 15005, 11042

Codes For Skin Replacement Surgery

• There are new codes for “Surgical Preparation,” formally called Wound Bed Preparation.

• CPT 15000 & 15001 have been deleted.

• The new Codes are:
• 15002
• 15003
• 15004
• 15005

• CPT 15002 – Surgical Preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children.

• CPT 15003 – Each additional 100sq cm or each additional 1% of body are of infants and children.

• CPT 15004 - Surgical Preparation or creation of recipient site by excision of open wounds, burn
eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, face, scalp, eyelids, neck ears, orbits, genitalia, hands, feet and/or multiple digits; first 100 sq cm or 1% of body area of infants and children.

• CPT 15005 - Each additional 100sq cm or each additional 1% of body are of infants and children.


Skin Replacement (CPT codes 15002 - 15005)

1. Per the definitions and the guidelines in CPT Code Book codes CPT codes 15002/15005 are not appropriate codes to use when performing a non-surgical application of a skin substitute.

2. CPT code 15002/15005 are only appropriately used in place of service inpatient hospital, outpatient hospital or ambulatory surgical center with regional or general anesthesia to resurface  an area damaged by burns, traumatic injury or surgery. An operative report is required and must be available upon request.


Coding Guidelines

1. Active wound care, performed with minimal anesthesia is billed with either CPT code 97597 or  97598.

2. Significant debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 – 11047.

3. CPT codes 11043, 11046, 11044, and 11047 are usually appropriately billed in place of service inpatient hospital, outpatient hospital or ambulatory care center (ASC). Billing of these codes in another place of service is most likely a billing error and thus the service will be denied. If a  provider feels that CPT 11043, 11046, 11044, or 11047 were actually performed in another place  of service, a review of the denied claim should be requested and documentation, including an
operative report, should be submitted.

4. Use CPT codes 15271 - 15278 for the surgical preparation or creation of recipient site for the  tissue skin graft.

5. To bill for an Apligraf® (HCPCS Q4101) package (equal to 44-sq. cm.). If more than 44-sq. cm. is needed for additional grafting, bill according to the number of single units of Apligraf®, indicate Apligraf® in Item 19 of the CMS 1500 Claim Form or the Comment Field for EMC claims.

6. Payment for Apligraf® for any single ulcer will not be made for re-treatment within 1 year after initial treatment.

7. Dermagraft® (HCPCS Q4106) is supplied frozen in a clear bag containing one piece of approximately 2 in. x 3 in. (5 cm. x 7.5 cm.) for a single use application.

8. Claims submitted for skin substitutes should bill the actual size used rounding up to the next whole number.

9. When submitting a claim for skin substitutes, providers are required to accept assignment for this service. Providers, who do not accept assignment, should bill the skin product on a separate claim from other services performed on the same day.

10. Products such as Integra are classified by the Federal Drug Administration as wound dressing and are thus not payable separately by Medicare Part B for outpatient services. The application of Integra or similar FDA classified products may be payable as an inpatient for its FDA approved indication for the treatment of life-threatening full-thickness or deep partial-thickness burns.

11. For services on or after November 1, 2007, the Oasis® Wound Matrix is covered and separately payable when used according to FDA labeled indications and in accordance with accepted standards of medical/surgical practice.

12. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the facility: outpatient hospital, (22), emergency room (23), and ambulatory surgical center (24).

13. Payable places of service for TheraSkin® (HCPCS code Q4121) if billed by the physician or nonphysician
practitioner: office (11), urgent care facility (20), and independent clinic (49).



Billing Guidelines

Wound Care (CPT Codes 97597, 97598 and 11042-11047)

1. Active wound care procedures are performed to remove devitalized and/or necrotic tissue to promote healing. Debridement is the removal of foreign material and/or devitalized or contaminated tissue from or adjacent to a traumatic or infected wound until surrounding healthy tissue is exposed. These services are billed when an extensive cleaning of a wound is needed prior to the application of primary dressings or skin substitutes placed over or onto a wound that is attached with secondary dressings.

2. Typically bill CPT 97597 and/or CPT 97598 for recurrent wound debridements when medically reasonable and necessary.

3. CPT 97597 and/or CPT 97598 are not limited to any specialty as long as it is performed by a health care professional acting within the scope of his/her legal authority.

4. CPT code 97597 and 97598 require the presence of devitalized tissue (necrotic cellular material). Secretions of any consistency do not meet this definition. The mere removal of secretions (cleansing of a wound) does not represent a debridement service.

5. The use of CPT codes 11042-11047 is not appropriate for the following services: washing bacterial or fungal debris from lesions, paring or cutting of corns or calluses, incision and drainage of abscess including paronychia, trimming or debridement of nails, avulsion of nail plates, acne surgery, destruction of warts, or burn debridement. Providers should report these procedures, when they represent covered, reasonable and necessary services, using the CPT codes that describe the service supplied.

6. When hydrotherapy (whirlpool) is billed by a physical therapist with CPT codes 97597 or 97598, the documentation must reflect the clinical reasoning why hydrotherapy was a necessary component of the total wound care treatment for removing of devitalized and/or necrotic tissue. The documentation must also reflect that the skill set of a physical therapist was required to perform this service in the given situation.

7. Separate billing of whirlpool (97022) is not permitted with 97597-97598 unless it is provided for a different body part than the wound care treatment body part.

8. Local infiltration, such as a metatarsal/digital block or topical anesthesia, is included in the reimbursement for debridement services and is not separately payable. Anesthesia administered by or incident to the provider performing the debridement procedure is not separately payable.

9. CPT Codes 97597 and 97598 are considered “sometimes” therapy codes. If billed by a physical therapist when the patient is under a home health benefit, it may be covered by the Home Health agency, if part of their Plan of Care. If it is a physician or nonphysician practitioner that is billing these “sometimes” therapy codes, it is paid under Part B even if the beneficiary is under an active home health plan of care. CMS Publication 100-02, Medicare Coverage Policy Manual, Chapter 7 – Home Health Services, Section 10.11 – Consolidated Billing, C. Relationship Between Consolidated Billing Requirements and Part B Supplies and Part B Therapies Included in the Baseline Rates That Could Have Been Unbundled Prior to HH PPS That No Longer Can Be Unbundled which states: Physician services or nurse practitioner services paid under the physician fee schedule are not recognized as home health services included in the PPS rates. Supplies incident to a physician service or related to a physician service billed to the Medicare contractor are not subject  to the consolidated billing requirements.

10. CPT code 97602 has been assigned a status indicator "B" in the Medicare Physician Fee Schedule Database (MPFSDB), meaning that it is not separately payable under Medicare.

11. Documentation must support the HCPCS being billed.

12. Payment for low frequency, non-contact, non-thermal ultrasound treatment (97610) is included in the payment for the treatment of the same wound with other active wound care management CPT codes (97597-97606) or wound debridement CPT codes (11042-11047, 97597, 97598). Low frequency, non-contact, non-thermal ultrasound treatments would be separately billable if other active wound management and/or wound debridement is not performed.

13. Infrared (97026), ultra-sound thermal (97035), phototherapy-ultraviolet (97028) modalities are not payable per the LCD.

Coding Guidelines

1. Debridement of a wound, performed before the application of a topical or local anesthesia is billed with CPT codes 11042 - 11047. Wound debridements (11042-11047) are reported by depth of tissue that is removed and by surface area of the wound. When performing debridement of a single wound, report depth using the deepest level of tissue removed. In multiple wounds, sum the surface area of those wounds that are at the same depth, but do not combine sums from different depths. See CPT coding guidance for proper use of the coding.

2. Do not report 11042 -11047 in conjunction with 97597-97602 for the same wound.

3. CPT code 11043, 11046 and 11044, 11047 may only be billed in place of service inpatient hospital, outpatient hospital or ambulatory surgical center (ASC).

4. CPT codes 11043, 11046 and 11044, 11047 are codes that describe deep debridement of the muscle and bone.

Reasons for Denial

1. Performing deep debridement in POS other than inpatient hospital, outpatient hospital or ASC
2. Billing of debridement by unqualified personal.

Administrative denial and Clinical denial - patient responsibility

Administrative Denials

An “administrative denial” occurs when authorization or payment for a particular health care benefit or service is denied because Harvard Pilgrim determines:
• The service is not covered under the member’s policy at the time the service is requested or provided
• A covered service is provided without primary care physician (PCP) approval or Harvard Pilgrim notification/authorization  (when required)
• A limited benefit has been exhausted

Member Liability
Members may be held financially liable for the cost of most services denied for administrative reasons. Members may not be held liable for the cost of services provided without required notification when an in-network provider is responsible for notifying Harvard Pilgrim. (Refer to “Failure to Notify” in the Notification Policy.) Explanation codes (EX codes) on the Explanation of Payment (EOP) indicate when a member may be held financially responsible.


Clinical Denials
Prior authorization is required for selected elective (non-urgent) services. A clinical denial occurs when a Harvard Pilgrim UM physician or designee denies authorization (and payment), or ends coverage, for a particular health care service because service specific medical necessity criteria were not met.


Member Liability
Members may be held liable for the cost of services that are denied prospectively. Explanation codes (EX codes) on the Explanation of Payment (EOP) indicate when a member may be held financially responsible. Members may not be held liable for the cost of services provided without required authorization when an in-network provider is responsible for obtaining prior approval. (Refer to “Failure to Notify” in the Notification Policy.)

DENIAL CODE PR 49 and PR 170 - Routine exam not covered denial

Q: We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?

Routine examinations and related services are not covered.

A: This denial is received when the claim is for a routine/preventive exam or a diagnostic/screening procedure, done in conjunction with a routine/preventative exam.

• Medicare does not cover diagnostic/screening procedures, or evaluation and management (E/M) services, for routine or screening purposes, such as an annual physical.

• Before submitting a claim, you may access the LCD and procedure to diagnosis lookup tool and search by procedure and diagnosis codes to determine if the procedure code to be billed is payable for a specific diagnosis (e.g., if the combination exists in an LCD).

• Refer to "Active, Future, and Retired LCDs" medical coverage policies for a list of procedure codes related to services addressed in the local coverage determination (LCD), and the diagnoses for which a service is/is not considered medically reasonable and necessary.

• Medicare does cover certain preventive services.


Make the necessary correction(s) and resubmit the claim, if applicable. Submit corrected line(s) only. Resubmitting the entire claim will result in a duplicate claim denial.

• If a payable diagnosis is indicated in the patient's encounter/service notes or record, correct the diagnosis and resubmit the claim.

• If a covered preventive service was coded wrong, correct the code and submit the corrected claim.

Q: We received a denial with claim adjustment reason code (CARC) PR 170. What steps can we take to avoid this denial?

This payment is denied when performed/billed by this type of provider.

A: This denial is received when services furnished or ordered by a chiropractor are not related to treatment by means of manual manipulation of the spine to correct a subluxation. Chiropractic services for treatment by means of manual manipulation of the spine to correct a subluxation are covered by Medicare. All other services furnished or ordered by a chiropractor are not.

• When billing HCPCS 98940, 98941 and 98942 for services related to active/corrective treatment for acute or chronic subluxation, a modifier is required. If the claim is submitted without the applicable modifier, services are considered maintenance therapy, and the claim will deny.

Payment included in another service - CO 97, M15, M144 AND N70

We received a denial with claim adjustment reason code (CARC) PR 49. What steps can we take to avoid this denial?
Routine examinations and related services are not covered.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark codes (RARCs) noted on the remittance advice and then refer to the specific resources/tips outlined below to avoid this denial.


M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.
• The service billed was paid as part of another service/procedure for the same date of service. Separate payment is never made for routinely bundled services and supplies. Bundled services should be billed to Medicare only when a denial is needed for a secondary payer.

The following procedures are examples of bundled services commonly seen with this denial.
• 94760: Noninvasive oximetry
• 97010: Hot/cold packs
• 99071: Educational supplies
• 99080: Special reports or forms
• 99090: Analysis of clinical data
• 99100: Special anesthesia services
• A4500: Surgical tray

• Check the procedure code on the First Coast fee schedule lookup tool. Scroll down to policy indicators and review code status. If status is equal to “b,” the service/procedure is not paid separately, not even with a modifier.



M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.
• The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable.
• If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.
• If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.
• Modifier 54: pre-and intra-operative services performed
• Modifier 55: post-operative management services only
• Modifier 56: pre-operative services only
• Refer to Modifier FAQs for additional information.
• See the Centers for Medicare & Medicaid Services (CMS) Internet-only manual (IOM), publication 100-04, chapter 12, section 40 external pdf file for additional guidance on global surgery.
• Resources available through the First Coast University external link:
• To understand how billing for services or procedures performed in the global surgery period can be affected, complete the free Web-based training (WBT) Introduction to Global Surgery -- Part B


N70 – Consolidated billing and payment applies.
• The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.
• Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.
• Always check beneficiary eligibility prior to submitting claims to Medicare.
• Click here for ways to verify beneficiary eligibility and get home health episode’s start and/or end date, if applicable.
• You may also look up home health provider information, including servicing provider number, by clicking here zip.gif.
• The services billed are subject to consolidated billing requirements by the Home Health Agency (HHA) while the beneficiary is under a home health plan of care authorized by a physician. The HHA is responsible for providing these services, either directly or under arrangement.