NC Department of Health and Human Services north carolina medicaid Health Check Seminar September 2012 Presented by: HP Enterprise Services DMA north carolina medicaid Health Check Resources • DMA Website – www.ncdhhs.gov/dma • Health Check Billing Guide • EPSDT Policy Instructions (updated 1/11/2010) • Request for Non-Covered Services Forms DMA north carolina medicaid For Providers EPSDT and Health Check DMA north carolina medicaid Fee Schedules Fee Schedules DMA north carolina medicaid Who’s Who in Medicaid • Centers for Medicare and Medicaid Services – CMS • Department of Health and Human Services – DHHS • Division of Medical Assistance – DMA DMA north carolina medicaid Who’s Who in Medicaid • Department of Social Services – DSS • HP Enterprise Services – HPES • Computer Sciences Corporation – CSC DMA north carolina medicaid EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) MEDICAID FOR CHILDREN Contact: EPSDT Nurse Consultant Division of Medical Assistance Telephone #: 919-855-4260 FAX #: 919-715-7679 DMA north carolina medicaid EPSDT Websites Basic Medicaid and N.C. Health Choice Billing Guide http://www.ncdhhs.gov/dma/basicmed/ Health Check Billing Guide http://www.ncdhhs.gov/dma/healthcheck/ EPSDT Provider Page http://www.ncdhhs.gov/dma/provider/epsdthealt hcheck.htm DMA north carolina medicaid EPSDT Provider Website DMA north carolina medicaid EPSDT Provider Website DMA north carolina medicaid Provider Responsibility • Verify Recipient Eligibility • Carolina ACCESS • Health Check Overview • Maintain Medical Records • Health Check Billing Requirements DMA north carolina medicaid Eligibility Verification Methods • NCECSWeb Tool – Free Service – Need Submitter ID & Password • Automated Voice Response (AVR) System – 1-800-723-4337 • EDI Vendor DMA north carolina medicaid Verify Eligibility Use any of these methods to search Tips: Use MPN or NPI If no date is keyed it will reflect eligibility for the date of search Can not check future date until the first of that month Can search back 365 days DMA north carolina medicaid Eligibility Results 123456789k 08/01/2012 08/31/2012 Jane Doe 123456789k 1/1/1960 08/01/2012- 08/31/2012 987654321A DMA north carolina medicaid Carolina ACCESS (CA) • Primary Care medical home for enrolled recipients • Obtain referral from Primary Care Provider • Referring NPI reported on claim • More information: Basic Medicaid and N.C. Health Choice Billing Guide Section 6- Managed Care Programs DMA north carolina medicaid CA Override Request • Considered only for extenuating circumstances http://www.ncdhhs.gov/dma/ca/CAOverrideForm.pdf DMA north carolina medicaid Carolina ACCESS Denial Codes – EOB 270 • Billing provider is not the recipient’s Carolina ACCESS PCP. Authorization is missing or unresolved – EOB 286 • Incorrect authorization number on claim form. Verify number and re-file claim DMA north carolina medicaid Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements DMA north carolina medicaid Health Check/EPSDT Overview • Important because… – Provides for early and regular medical, developmental, dental screenings and ongoing surveillance for all Medicaid recipients under the age of 21 – Part of the federal Medicaid EPSDT requirement to provide medically necessary health care DMA north carolina medicaid Screening Assessments • Health Check recommends regular medical screening assessments (well-child visits) for recipients • Screening, diagnostic and treatment services are FREE of charge to the recipient DMA north carolina medicaid Health Check/EPSDT Recommended Periodicity Schedule Within 1st month 9 or 15 months 2 months 12 months 4 months 18 months 6 months For children ages 2 through 20, annual visits are recommended DMA north carolina medicaid Periodic Health Check Screening • Require all age-appropriate components – Developmental Screening – Vision Screening – Hearing Screening – Dental Screening – Immunizations DMA north carolina medicaid Interperiodic Health Check Screening • Require all age-appropriate components EXCEPT – Developmental Screening – Hearing Screening – Vision Screening • Screening may be performed outside of the periodicity schedule • All electronic claims should list referral code indicator “E” when a referral is made for follow-up DMA north carolina medicaid Health Check Screening Assessment Components • Comprehensive unclothed physical assessment • Comprehensive health history • Nutritional assessment • Anticipatory guidance and health education • Measurements, blood pressure and vital signs DMA north carolina medicaid Health Check Screening Assessment Components • Developmental surveillance • Immunizations • Vision screening • Hearing screening • Dental screening • Laboratory procedures DMA north carolina medicaid Developmental Screening • Includes physical and mental development • Required component of a Periodic Screening at the following ages: – 6, 12, and 18 or 24 months old – 3, 4, and 5 years old • Must use a standardized and validated screening tool • CPT code 96110 with EP modifier DMA north carolina medicaid Developmental Screening • Autism Screening CPT Code 99420 with EP modifier • Screening at ages 18 and 24 months DMA north carolina medicaid Developmental Screening Cont. • Health Risk Assessments and Behavioral/Mental Health Screening – CPT Code • 99420 EP modifier • Smoking/Tobacco Use Cessation Counseling – CPT Codes • 99406 EP modifier • 99407 EP modifier • Alcohol/Substance Abuse Structured Screening and Brief Intervention – CPT Codes • 99408 EP modifier • 99409 EP modifier DMA north carolina medicaid Break Time….. See you back in 15 minutes!! DMA north carolina medicaid Immunizations • Same provider • Same date of service as Health Check screening • Same location as Health Check screening • EP modifier appended to the immunization administration CPT code – Recipients from birth through age 20 DMA north carolina medicaid Immunizations • The North Carolina Immunization Program (NCIP) • Vaccines for Children (VFC) • Birth through 18 years of age - no charge • Reimbursement for the administration of vaccines • EP modifier required DMA north carolina medicaid Procedure Code Description 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) 90472+ Immunization administration (includes percutaneous, (add-on-code) intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid) each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure 90473 Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid) 90474+* Immunization administration by intranasal or oral route; (add-on-code) each additional vaccine (single or combination vaccine/toxoid) List separately in addition to code for primary procedure DMA north carolina medicaid Vision Screening • Required for Periodic Examinations beginning at age 3 through 10 years • Age 11- screening needed only once every three years • CPT code 99172 or 99173 with EP modifier DMA north carolina medicaid Hearing Screening • Objective screenings using an otoacoustic auditory emission (OAE) tool or audiometer • Performed annually for ages 4-10 • All other ages, selective screening based on assessment of risk • CPT code 92551, 92552, or 92587 with EP modifier DMA north carolina medicaid What if the hearing or vision component cannot be performed because…. • Uncooperative, blind, deaf, or autistic • Document the date of service and reason why unable to perform screening • Submit claim without component CPT code DMA north carolina medicaid Dental Screening • An oral screening is to be performed at every Health Check visit • Referral to a dentist is recommended for every child before age 1 and required at age of 3 • Dental Varnishing allowed once every 60 calendar days – D1206 and D0145, no EP modifier DMA north carolina medicaid Frequently Asked Questions • Is Dental Varnishing a requirement of the Health Check program? • Answer: No • Is Dental Varnishing separately reimbursable in addition to a Health Check visit? • Answer: Yes DMA north carolina medicaid Laboratory Procedures • Laboratory procedures include: – Hemoglobin or Hematocrit – Newborn Metabolic/Sickle Cell Screening – Tuberculin Test – Lead testing • Included in Health Check fee when billed on same date of service DMA north carolina medicaid Provider Responsibility Verify Recipient Eligibility Carolina ACCESS Health Check Overview Maintain Medical Records Health Check Billing Requirements DMA north carolina medicaid Claim Submission • Electronic submission • Software Vendor or Clearinghouse • NC Electronic Claims Submission (NCECSWeb Tool) • Paper submission – For claims meeting exception criteria only DMA north carolina medicaid Health Check Billing Requirements What are the six billing requirements specific to the Health Check Program? DMA north carolina medicaid Requirement 1: • Identify and record • Medical diagnoses diagnosis code – Listed after primary, – CMS-1500, block 21 and before immunization diagnoses • Primary diagnosis first – Periodic- V20.2 • Immunization diagnosis – Interperiodic V70.3 code – Required when one or more immunizations are provided as the only service DMA north carolina medicaid Requirement 2: • Identify and record • Vision CPT codes 99172 preventive medicine or 99173 with EP modifier code and component codes • Hearing CPT codes • Developmental screening 92551, 92552, or 92587 CPT codes 96110, with EP modifier 99420, 99406, 99407, 99408, 99409 with EP modifier DMA north carolina medicaid Requirement 3: • EP is a required modifier for all Health Check claim details – Screening assessments – Vision, Hearing, and Developmental screening – Immunization administration DMA north carolina medicaid Requirement 4: • Record Referrals: – List referral code indicator “E” for claims submitted via NCECSWeb Tool – List referral code indicator “F” when a referral is made for Family Planning services DMA north carolina medicaid Requirement 5: • Next Screening Date – Systematically entered according to the predetermined periodicity schedule – Provider-entered Next Screening Date – Systematically entered Next Screening Date DMA north carolina medicaid Requirement 6: • Identify and Record Immunization Administration CPT Code(s) and the EP Modifier • Refer to immunization guidelines DMA north carolina medicaid Preventive Medicine CPT Codes Age New Patient Established Append EP Patient Modifier Under age 1 year 99381 99391 Yes 1 through 4 years 99382 99392 Yes 5 through 11 years 99383 99393 Yes 12 through 17 years 99384 99394 Yes 18 through 20 years 99385 99395 Yes DMA north carolina medicaid Frequently Asked Question • Can I get paid for a sick visit and a well visit on the same date of service? • Answer: No • If they are sick, treat the visit as a sick visit and reschedule the well check DMA north carolina medicaid Billing Information • Report CA Overrides on the NCECSWeb Tool using: – “Referring Physician Provider Number” (Carolina ACCESS Physician Number) • Electronic Funds Transfer (EFT) • Checkwrite schedule • Cut-off date and time • http://www.ncdhhs.gov/dma/provider/calendar.htm DMA north carolina medicaid Billing Tips-All Providers Two Health Check screening assessments on different dates of service cannot be billed together Can be billed when performed during a periodic or interperiodic Health Check assessment for ages 11-20 – CPT codes: 99406, 99407, 99408, 99409, Can be billed when performed during a periodic or interperiodic Health Check assessment for ages birth through 20 – CPT code: 99420 Immunizations and therapeutic injections may be billed on same claim/date of service DMA north carolina medicaid Billing Tips - Private Sector Provider • Health Check screening and office visit with different dates of service must be billed separately • Health Check screening assessment and office visit cannot be paid initially on the same date of service • For denied claim to be reconsidered – Submit an adjustment with medical documentation and EOB attached • AVR and claim status DMA north carolina medicaid Billing Tips - Local Health Department • Two Health Check screenings on different dates of service cannot be billed on the same claim form • An immunization administration fee may be billed if the immunization is provided in addition to a Health Check screening visit. DMA north carolina medicaid Health Check Coordinators (HCCs) • Assist parents and providers in assuring that Medicaid-eligible children have ACCESS to Health Check services • Provide education and outreach services in 100 NC counties and the Qualla Boundary DMA north carolina medicaid Health Check Common EOBs EOB 10 EOB 1769 – Diagnosis or service – No additional payment invalid for recipient age made for vision, hearing and/or developmental screening services EOB 1036 – Thank you for reporting EOB 1770 vaccines – Invalid procedure/modifier/ diagnosis DMA north carolina medicaid Health Check References • Billing reference sheet • Claim examples • Immunization billing • Local Health reference sheet Department HSIS screens • Resource list • N.C. Periodicity Schedule and Coding Matrix http://www.ncdhhs.gov/dma/healthcheck/coding_matrix.pdf DMA north carolina medicaid Frequently Used Forms Medicaid Resolution Inquiry DMA north carolina medicaid Medicaid Overrides • Resolution Inquiry Form – Use only when requesting • Time Limit Override • Third Party Override • Medicare Override • HMOs • Attached with Explanation of Benefits (EOB) and paper claim • Mail to: HP Enterprise Services PO Box 300009 Raleigh, NC 27622 DMA north carolina medicaid Primary Insurance • Private Insurance pays, submit electronic claim to Medicaid • Non-payment indicated? Submit claim on paper – Attach Medicaid Resolution Inquiry Form, claim, and primary EOB • Check “Third Party Override” box – Applied to the Deductible, Non-Covered Service, Policy Terminated – Exceeds maximum benefits for the year DMA north carolina medicaid DMA-2057/Electronic Transmissions Update recipient’s commercial insurance information Transmit electronically via secured internet connection – New & preferred method Ability to send claim upon receipt of the confirmation e-mail from vendor HMS website http://ncprovider.hms.com DMA north carolina medicaid Contact Information • Automated Voice Response (AVR) System 1-800-723-4337 • Billing questions HP Enterprise Services 1-800-688-6696 or 919-851-8888, Option 3 • Provider enrollment CSC EVC Call Center 1-866-844-1113 or email NCMedicaid@csc.com DMA north carolina medicaid Review • A child comes in for a sports physical, outside of their periodicity schedule. Is this a periodic or interperiodic screening? • Answer: Interperiodic • What diagnosis code is required? • Answer: V70.3 DMA north carolina medicaid Review • True or False: An EP modifier is required when billing a health check visit code • Answer: TRUE DMA north carolina medicaid Provider Responsibility • Verify Recipient Eligibility • Carolina ACCESS • Health Check Overview • Maintain Medical Records • Health Check Billing Requirements DMA north carolina medicaid Review • True or False: Although Medicaid ID cards are issued annually, eligibility information can still change on a monthly basis • Answer: TRUE DMA Thank You ANY QUESTIONS?
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