Durable Medical Equipment Billing Tips - Arkansas Medicaid

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Durable Medical Equipment. Billing Tips. Provider Reference Supplement. HP Enterprise Services, Arkansas Title XIX. Document Date: 5/12/2010 ...
Durable Medical Equipment Billing Tips Provider Reference Supplement

HP Enterprise Services, Arkansas Title XIX Document Date: 5/12/2010

HP Enterprise Services Arkansas Title XIX Account 500 President Clinton Avenue, Suite 400 Little Rock, Arkansas 72201 (501) 374-6608

HP Enterprise Services and the HP Enterprise Services logo are registered trademarks of HP Enterprise Services. All other logos, trademarks or service marks used herein are the property of their respective owners. HP Enterprise Services is an equal opportunity employer and values the diversity of its people. © 2010 HP Enterprise Services. All rights reserved.

Contents Introduction ..................................................................................................................... 5 Restricted Aid Categories ................................................................................................ 6 DME Exclusions .............................................................................................................. 9 Prescription and Referral Renewal ............................................................................... 9 Getting a Prior Authorization ........................................................................................ 9 DME Services Provided ................................................................................................ 11 Place of Service Codes ................................................................................................. 12 Modifiers ....................................................................................................................... 14 Paper Billing Instructions ............................................................................................... 15 Contact Information ....................................................................................................... 20

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Arkansas Medicaid DME Billing Tips

Introduction This Billing Tips document serves as a training supplement for Arkansas Medicaid providers, but does not supersede official program documentation including: Arkansas Medicaid Provider Reference manuals, Official Notices and transmittal letters published by the Division of Medical Services and distributed by HP Enterprise Services. This document focuses on Arkansas Medicaid eligibility and billing issues and incorporates the following quick reference items for your convenience: 

Consolidated list of restricted aid categories



DME Exclusions



DME Covered Services



Place of Service Codes



Modifiers



Paper Billing Instructions

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Arkansas Medicaid DME Billing Tips

Restricted Aid Categories Many providers ask a question that is closely related to eligibility: “Is there a list of aid categories that require a primary care physician?” The answer is no. Arkansas Medicaid’s primary care case management program, ConnectCare, requires Medicaid beneficiaries and waiver participants to enroll with a primary care physician (PCP) unless specifically exempt from that requirement. See the following sections of your Arkansas Medicaid provider reference manual for more information: 

Section 171.000, which lists the groups of individuals who may not enroll with a PCP



Section 176.000, which lists Medicaid covered services that do not require PCP referral

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The table below lists and briefly describes restricted aid categories. Post it at your workstation to use as a convenient quick reference:

Aid Category

Restriction

01 ARKids First-B

Beneficiaries may have co-payment requirements.

(PCP Required)

Beneficiaries may be ineligible for certain services (see the ARKids First-B provider manual for exclusions.)

03 CMS (Children’s Medical Services)

All services must be prior authorized by the CMS office.

Non-Medicaid (No PCP Required) 04 DDS (Developmental Disability Services) Non-Medicaid (NO PCP Required)

DDS non-Medicaid provider ID numbers end with ‘86’. DDS non-Medicaid beneficiary ID numbers begin with ‘8888’. Only DDS non-Medicaid providers may bill for DDS nonMedicaid beneficiaries. DDS beneficiaries may be dually eligible and receive additional services in another category.

*6 Medically Needy Exceptional

Beneficiaries are eligible for a full range of benefits except nursing facility and personal care.

(PCP Required) *7 Spend Down (No PCP Required) (PCP required for Breast Care, 07) 08 Tuberculosis (NO PCP Required)

Beneficiaries must pay toward medical expenses when income and resources exceed the Medicaid financial guidelines. Note: Aid category 07 BCC has full benefits. Beneficiary coverage includes drugs, physician services, outpatient services, rural health clinic encounters. Federally Qualified Health Center (FQHC) and clinic visits for TB-related services only.

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Arkansas Medicaid DME Billing Tips

Aid Category

Restriction

*8 QMB (Qualified Medicare Beneficiary)

Medicaid pays Medicare premiums, coinsurance and deductible.

(No PCP Required)

If the service provided is not a Medicare covered service, Medicaid will not pay for the service under the QMB policy. Note: Aid category 18 S has full benefits.

61 PW-PL (Pregnant Woman Infants and Children Poverty level)

This category contains both pregnant women and children. Providers must use the last three-(3) digits of the Medicaid ID number to determine benefits.

(No PCP Required For Pregnant Woman)

When the last three (3) digits are in the 100 series (i.e., 101, 102, etc.), the beneficiary is eligible as an adult and is eligible for pregnancy-related services only.

(PCP Required for the Infants and children)

When the last three (3) digits are in the 200 series (i.e., 201, 202, etc.), the beneficiary is eligible as a child and receives a full range of Medicaid services. Note: Plan description “PW unborn ch-noster/FP cov” indicates there is no sterilization or family planning benefits for the expectant mother.

62 PW-PE (Pregnant Woman Presumptive Eligibility)

A temporary aid category that pays for ambulatory, prenatal services only.

(No PCP Required) 69 Women’s Health Wavier (No PCP Required)

Medicaid pays for family planning preventative services only, such as birth control or counseling. A claim for a beneficiary in this category must contain both a family planning diagnosis code and a family planning procedure code.

58, 78, 88 SLIMB (Specified Low Income Medicare Beneficiary)(SMB)

Medicaid pays only their Medicare premium.

(No PCP Required)

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DME Exclusions Services that are not covered under the Arkansas Medicaid Prosthetics Program include but are not limited to: A. Over-the-counter items provided through the Arkansas Medicaid Pharmacy Program (except as specified). B. Over-the-counter drugs (except as specified). C. Products that bear the Federal legend “Caution: Federal Law Prohibits Dispensing without a Prescription” (except as specified). D. Specialized wheelchair equipment that has been previously purchased by any payer. Specialized wheelchair equipment may not be reordered unless the patient’s condition changes and necessitates a change in prescription. This change in condition must be thoroughly documented. E. Wheelchairs for individuals under 21 years of age within two years of the purchase of a specialized wheelchair. F. Wheelchairs for individuals age 21 and over within five years of the purchase or rental of a wheelchair. G. Foodstuffs. H. Hyperalimentation. I.

Services that duplicate any other service provided to the patient or that replace existing patient supports.

Prescription and Referral Renewal At least once every 6 months, but within 30 working days before the end of currently prescribed or prior authorized prosthetics services, the prosthetics provider must obtain a new prescription from the beneficiary’s primary care physician and, if applicable, send a new prior authorization form to the applicable entity.

Getting a Prior Authorization Requests for prior authorization will be handled by either Utilization Review, a section within the Division of Medical Services or by the Arkansas Foundation for Medical Care (AFMC), depending on the service that is being requested. A. To request prior authorization for wheelchair and wheelchair seating systems, providers must use form DMS-679 and send the information to the Utilization Review Section. The original and the first copy of the Medical Equipment Request for Prior Authorization and Prescription Form (form DMS-679) must be forwarded to the Division of Medical Services, Utilization Review Section. The third copy of the form must be retained in the provider’s records. B. Requests for prior authorization of some medical supplies (i.e., compression burn garments), orthotic appliances, prosthetic devices and all durable medical equipment, excluding wheelchairs and wheelchair seating systems, must be submitted to AFMC on the Prescription & Prior Authorization Request for Medical 9

Arkansas Medicaid DME Billing Tips

Equipment Excluding Wheelchairs & Wheelchair Components Form (DMS-679A). See section V of your provider manual for the form.

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DME Services Provided Service

Age

Benefit Limit/Restrictions

Diapers and Underpads

3 and older

$130 per month

Apnea Monitors

Under age 1

PA required

Augmentative Communication Device

All Ages

$7500 lifetime/PA required for age 21+

Electronic Blood Pressure Monitor and Cuff

All Ages

PA required

Enteral Nutrition Infusion Pump and Enteral Feeding Pump Supple Kit

Under 21

1 per day/PA required

Home Blood Glucose Monitor

All Ages

Pregnant Women Only

Insulin Pump and Supplies

All Ages

PA required

MIC-KEY Skin Level Gastrostomy Tube (MicKey Button) and Supplies

Under 21

2 per SFY/PA required

Specialized Rehabilitative Equipment

All Ages

Some may require PA

Specialized Wheelchairs and Wheelchair Seating Systems

Two through Adult

Some require PA

Medical Supplies

All Ages

$250 per month

Nutritional Formula

Under Age 21

30 units per day

Food Thickeners

All Ages

N/A

Orthotic Appliances

All Ages

$3000 per SFY for age 21+ PA required for age 21+

Prosthetic Devices

All Ages

$20000 per SFY for age 21+ PA required for age 21+

Oxygen and Oxygen Supplies

All Ages

PA required

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Arkansas Medicaid DME Billing Tips

Place of Service Codes Electronic and paper claims require the same national place of service (POS) code. Place of Service

POS Codes

Inpatient Hospital

21

Outpatient Hospital

22

Doctor’s Office

11

Patient’s Home

12

Day Care Facility

52

Night Care Facility

52

Nursing Facility

32

Skilled Nursing Facility

31

Ambulance

41

Other Locations

99

Independent Laboratory

81

Ambulatory Surgical Center

24

Residential Treatment Center

56

Specialized Treatment Facility

56

Comprehensive Outpatient Rehabilitative Facility

62

Independent Kidney Disease Treatment Center

65

Inpatient Psychiatric Facility

51

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Arkansas Medicaid DME Billing Tips

Modifiers Modifiers EP-Service provided as part of EPSDT Program KH-Durable Medical Equipment (DME) item, initial claim, first month's rental NU-New Equipment RR-Durable Medical Equipment (DME) Rental U1-Medicaid Level of Care 1 (defined by state) U2-Medicaid level of Care 2 (defined by state) U3-Medicaid level of care 3 (defined by state) U4-Medicaid level of care 4 (defined by state) U5-Medicaid level of care 5 (defined by state) UE-Used durable medical equipment (DME) 52-Reduced Services

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Paper Billing Instructions Field Name and Number

Instructions for Completion

1.

Not required.

(type of coverage)

1a. INSURED’S I.D. NUMBER (For Program in Item 1)

Beneficiary’s or participant’s 10-digit Medicaid or ARKids First-A or ARKids First-B identification number.

2.

PATIENT’S NAME (Last Name, First Name, Middle Initial)

Beneficiary’s or participant’s last name and first name.

3.

PATIENT’S BIRTH DATE

Beneficiary’s or participant’s date of birth as given on the individual’s Medicaid or ARKids First-A or ARKids First-B identification card. Format: MM/DD/YY.

SEX

Check M for male or F for female.

4.

INSURED’S NAME (Last Name, First Name, Middle Initial)

Required if insurance affects this claim. Insured’s last name, first name and middle initial.

5.

PATIENT’S ADDRESS (No. Street)

Optional. Beneficiary’s or participant’s complete mailing address (street address or post office box).

CITY

Name of the city in which the beneficiary or participant resides.

STATE

Two-letter postal code for the state in which the beneficiary or participant resides.

ZIP CODE

Five-digit ZIP code; nine digits for post office box.

TELEPHONE (Include Area Code)

The beneficiary’s or participant’s telephone number or the number of a reliable message/contact/ emergency telephone.

6.

PATIENT RELATIONSHIP TO INSURED

If insurance affects this claim, check the box indicating the patient’s relationship to the insured.

7.

INSURED’S ADDRESS (No., Street)

Required if insured’s address is different from the patient’s address.

CITY STATE ZIP CODE TELEPHONE (Include Area Code) 8.

PATIENT STATUS

Not required.

9.

OTHER INSURED’S NAME (Last name, First Name, Middle Initial)

If patient has other insurance coverage as indicated in Field 11d, the other insured’s last name, first name and middle initial. 15

Arkansas Medicaid DME Billing Tips

Field Name and Number

Instructions for Completion

a.

OTHER INSURED’S POLICY OR GROUP NUMBER

Policy and/or group number of the insured individual.

b.

OTHER INSURED’S DATE OF BIRTH

Not required.

SEX

Not required.

c.

EMPLOYER’S NAME OR SCHOOL NAME

Required when items 9 a-d are required. Name of the insured individual’s employer and/or school.

d.

INSURANCE PLAN NAME OR PROGRAM NAME

Name of the insurance company.

10. IS PATIENT’S CONDITION RELATED TO: a.

EMPLOYMENT? (Current or Previous)

Check YES or NO.

b.

AUTO ACCIDENT?

Required when an auto accident is related to the services. Check YES or NO.

PLACE (State)

If 10b is YES, the two-letter postal abbreviation for the state in which the automobile accident took place.

OTHER ACCIDENT?

Required when an accident other than automobile is related to the services. Check YES or NO.

c.

10d. RESERVED FOR LOCAL USE 11. INSURED’S POLICY GROUP OR FECA NUMBER

Not used. Not required when Medicaid is the only payer.

INSURED’S DATE OF BIRTH

Not required.

SEX

Not required.

b.

EMPLOYER’S NAME OR SCHOOL NAME

Not required.

c.

INSURANCE PLAN NAME OR PROGRAM NAME

Not required.

d.

IS THERE ANOTHER HEALTH BENEFIT PLAN?

When private or other insurance may or will cover any of the services, check YES and complete items 9a through 9d.

a.

12. PATIENT’S OR AUTHORIZED PERSON’S SIGNATURE

Not required.

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Field Name and Number

Instructions for Completion

13. INSURED’S OR AUTHORIZED PERSON’S SIGNATURE

Not required.

14. DATE OF CURRENT: ILLNESS (First symptom) OR INJURY (Accident) OR PREGNANCY (LMP)

Required when services furnished are related to an accident, whether the accident is recent or in the past. Date of the accident.

15. IF PATIENT HAS HAD SAME OR SIMILAR ILLNESS, GIVE FIRST DATE

Not required.

16. DATES PATIENT UNABLE TO WORK IN CURRENT OCCUPATION

Not required.

17. NAME OF REFERRING PROVIDER OR OTHER SOURCE

Primary Care Physician (PCP) referral is not required for prosthetics. If services are the result of a Child Health Services (EPSDT) screening/ referral, enter the referral source, including name and title.

17a. (blank)

The 9-digit Arkansas Medicaid provider ID number of the referring physician.

17b. NPI

Not required.

18. HOSPITALIZATION DATES RELATED TO CURRENT SERVICES

When the serving/billing provider’s services charged on this claim are related to a beneficiary’s or participant’s inpatient hospitalization, enter the individual’s admission and discharge dates. Format: MM/DD/YY.

19. RESERVED FOR LOCAL USE

Not used.

20. OUTSIDE LAB?

Not required.

$ CHARGES

Not required.

21. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY

Diagnosis code for the primary medical condition for which services are being billed. Up to three additional diagnosis codes can be listed in this field for information or documentation purposes. Use the International Classification of Diseases, Ninth Revision (ICD-9-CM) diagnosis coding current as of the date of service.

22. MEDICAID RESUBMISSION CODE

Reserved for future use.

ORIGINAL REF. NO.

Reserved for future use.

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Arkansas Medicaid DME Billing Tips

Field Name and Number

Instructions for Completion

23. PRIOR AUTHORIZATION NUMBER

The prior authorization or benefit extension control number if applicable.

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A.

DATE(S) OF SERVICE

The “from” and “to” dates of service for each billed service. Format: MM/DD/YY. 1. On a single claim detail (one charge on one line), bill only for services provided within a single calendar month. 2. Providers may bill on the same claim detail for two or more sequential dates of service within the same calendar month when the provider furnished equal amounts of the service on each day of the date sequence.

B.

PLACE OF SERVICE

Two-digit national standard place of service code. See Section 242.200 for codes.

C.

EMG

Not required.

D.

PROCEDURES, SERVICES OR SUPPLIES CPT/HCPCS

Enter the correct CPT or HCPCS procedure code from Sections 242.100 through 242.195.

MODIFIER

Modifier(s) if applicable.

E.

DIAGNOSIS POINTER

Enter in each detail the single number—1, 2, 3 or 4— that corresponds to a diagnosis code in Item 21 (numbered 1, 2, 3 or 4) and that supports most definitively the medical necessity of the service(s) identified and charged in that detail. Enter only one number in E of each detail. Each DIAGNOSIS POINTER number must be only a 1, 2, 3 or 4, and it must be the only character in that field.

F.

$ CHARGES

The full charge for the service(s) totaled in the detail. This charge must be the usual charge to any client, patient or other recipient of the provider’s services.

G.

DAYS OR UNITS

The units (in whole numbers) of service(s) provided during the period indicated in Field 24A of the detail.

H.

EPSDT/Family Plan

Enter E if the services resulted from a Child Health Services (EPSDT) screening/referral.

I.

ID QUAL

Not required.

J.

RENDERING PROVIDER ID #

The 9-digit Arkansas Medicaid provider ID number of the individual who furnished the services billed for in the detail.

NPI

Not required.

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Field Name and Number

Instructions for Completion

25. FEDERAL TAX I.D. NUMBER

Not required. This information is carried in the provider’s Medicaid file. If it changes, please contact Provider Enrollment.

26. PATIENT’S ACCOUNT N O.

Optional entry that may be used for accounting purposes; use up to 16 numeric or alphabetic characters. This number appears on the Remittance Advice as “MRN.”

27. ACCEPT ASSIGNMENT?

Not required. Assignment is automatically accepted by the provider when billing Medicaid.

28. TOTAL CHARGE

Total of Column 24F—the sum all charges on the claim.

29. AMOUNT PAID

Enter the total of payments previously received on this claim. Do not include amounts previously paid by Medicaid. *Do not include in this total the automatically deducted Medicaid or ARKids First-B co-payments.

30. BALANCE DUE

From the total charge, subtract amounts received from other sources and enter the result.

31. SIGNATURE OF PHYSICIAN OR SUPPLIER INCLUDING DEGREES OR CREDENTIALS

The provider or designated authorized individual must sign and date the claim certifying that the services were personally rendered by the provider or under the provider’s direction. “Provider’s signature” is defined as the provider’s actual signature, a rubber stamp of the provider’s signature, an automated signature, a typewritten signature or the signature of an individual authorized by the provider rendering the service. The name of a clinic or group is not acceptable.

32. SERVICE FACILITY LOCATION INFORMATION

If other than home or office, enter the name and street, city, state and ZIP code of the facility where services were performed.

a. (blank)

Not required.

b. (blank)

Not required.

33. BILLING PROVIDER INFO & PH #

Billing provider’s name and complete address. Telephone number is requested but not required.

a. (blank)

Not required.

b. (blank)

Enter the 9-digit Arkansas Medicaid provider ID number of the billing provider.

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Arkansas Medicaid DME Billing Tips

Contact Information Providers needing assistance on billing, enrollment or technical support should call HP Enterprise Services at one of the following assistance numbers: 

1.800.457.4454 (outside of Little Rock but in-state)



(501) 376-2211 (local or out-of-state)

Depending on the type of assistance needed, follow the instructions in the phone system to reach the appropriate department. The provider assistance departments are: 

Provider Assistance Center - The provider assistance center is open weekdays 8 a.m. to 5 p.m. to assist providers with claim issues, billing questions and denials.



EDI support center - The EDI Support Center is open weekdays 8 a.m. to 5 p.m. to assist providers with electronic claim submission issues, 997 batch responses, PES software downloads and setup support, software training and data transmission failures.



Medicaid Provider Enrollment - The Medicaid Provider Enrollment Unit is open weekdays 8 a.m. to 5 p.m. to assist providers with enrollment in the Arkansas Medicaid program, changing PCP caseloads and updating demographic information.



HP Enterprise Services Provider Representatives - HP Enterprise Services Provider Representatives are available to visit your facility by appointment. They assist providers with billing issues, software delivery and setup, escalated issues and policy questions. See the Arkansas Medicaid website for a list of representatives by counties.

Research Analyst - The PAC Research Analyst assist providers with escalated billing issues, claim appeals and special processing requests. See the Arkansas Medicaid website for contact information by county.

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