Payment Process by alicejenny


									Reimbursement Process
 NDMS Definitive Care
             Definitive Care

Definitive Care:
 Medical treatment or services or beyond emergency
 medical care, initiated upon inpatient admission to a
 NDMS hospital and provided for illnesses and injuries
 resulting directly from a specified public health
 emergency, or for injury, illnesses, conditions requiring
 non-deferrable medical treatment or services to maintain
 health when such medical treatment or services are
 temporarily not available as a result of the public health
                  (NDMS MOA, section 803)

           NDMS Coverage
NDMS Coverage:
 NDMS coverage begins when an FCC authorized
 placement of a patient, who has been evacuated from a
 disaster area, into an acute care hospital for impatient
 definitive care. NDMS payment ends when one of the
 follow occurs, whichever comes first: completion of
 medically indicated treatment (maximum of 30 days);
 exhaustion of the DRG payment schedule; voluntary
 refusal of care; patient returns home or to point of
 origin/fiscally comparable location or to destination of
 choice for patient (whichever costs less).

       Hospital Reimbursement
Inpatient Services:
   ─ Any inpatient care provided within the first 30 days of
     the patient’s initial placement with a NDMS hospital is

   ─ This could be multiple admissions as long as the dates
     of service are within the first 30 days (subject to
     Medicare readmission policies).

   ─ Claims will be adjudicated using Medicare policies.

         Hospital Reimbursement
Inpatient Services:
   ─ Reimbursement will be made at the lesser of (1) billed
     charges or (2) 110% of the amount of the Medicare
      • Hospitals will receive credit for the IPPS operating
        payment amount based on DRG and the hospital’s wage
        index value.
      • Hospitals will receive credit for the IPPS capital payment
        amount based on DRG and the hospital’s geographic
        adjustment factor.
      • Credits will be given for disproportionate share and/or
        indirect GME adjustments.
      • Cost outlier adjustments will be recognized, but direct
        pass-through components such as direct medical
        education will not.
      Practitioner Reimbursement
Practitioner Services:
  ─ Reimburse for medically-necessary professional
    services furnished to NDMS patients during the course
    of their NDMS-covered inpatient stay at a NDMS

  ─ Practitioner must be currently licensed to furnish the
    care provided and must not have been excluded from
    participation in federal health care programs.

  ─ Practitioner must provide certified data on the NDMS
    patient. Medical charts must support the billing of the

      Practitioner Reimbursement
Practitioner Services:
  ─ Reimburse lesser of (1) billed charges or (2) 100% of
    the amount of the Medicare physicians’ fee schedule.

  ─ Fee schedule allowance will not be adjusted for
    practitioners based on whether or not he/she is
    enrolled in the Medicare program and if enrolled
    whether or not he/she has signed a Medicare
    participation agreement.

           Coordination of Benefit
• If the Patient is covered by Medicare, TRICARE or the
 Department of Veterans Affairs – NDMS will not make
 additional payments and payments from these programs
 will constitute full reimbursement.

• If the Patient has private health insurance or non-federal
 public coverage other than Medicaid – the other insurance
 should be billed as the primary and NDMS can be billed
 as the secondary for the difference up to 110% of
 Medicare for Hospitals and 100% of Medicare for

• If the Patient only has Medicaid or Section 1011 coverage,
 NDMS should be billed as the primary.
     Claims Submission Process

• You can reference:

• UB-04 and CMS-1500 claim forms should be
 mailed to TrailBlazer Health

• Practitioners should submit a pay-to address on
 the CMS-1500 claim form

• Hospitals are not required to do so on the UB-04.

         Internal HHS Claims Review
 All denied claims automatically referred for review to
 determine if the claim should be paid by TrailBlazer

• Membership
     ─ ASPR Representative
     ─ Emergency Physician
     ─ HHS Contract Technical Representative
     ─ Ad hoc members as needed for questions
        • CMS Representative
           ─ Compliance or Payment
        • ACF Rep
        • Office on Disability
•   Denied claims to be referred to State Medicaid Agency.
               Payment Process

• Currently, TrailBlazer Health is handling the adjudication
 of claims and the production of Explanation of Benefits
 and Remittance Advices.

• NDMS/ASPR currently must pay providers directly once
 TrailBlazer Health has determined the amount of

               Payment Process

• The normal process for Federal Government payments to
 vendors requires that the vendor register in the Central
 Contractor Registry (CCR) at

• A pre-requisite as part of the CCR application process is
 to obtain a DUNS number from Dun and Bradstreet.

• Many hospitals already have a CCR registration as this is
 a pre-requisite for any Federal grant or contracting

         Payment Process Issues

• Most practitioner organizations have struggled with the
 DUNS/CCR application process.

• There is an alternative to DUNS/CCR.  A provider can fax
 in an ACH Vendor Enrollment form known as a SF-3881
 (a copy can be downloaded here:

         Payment Process Issues

• This will allow ASPR/NDMS to process a one-time
 Electronic Funds Transfer to the provider’s bank account.
 A new form must be faxed in for each payment expected.
 For example, there have been four rounds of claims
 payments for Haiti patients. If a provider had submitted a
 claim in multiple rounds, they would need to fax in an ACH
 Vendor Enrollment form for each round.

• The biggest issues seen to date have involved
 mismatches of Tax ID names.

           Payment Process Issues

• The Federal Government has strict policies about not making
 payments if the Tax ID name on the bank account does not
 match the name on the claims and remittance advices from
 TrailBlazer Health. Examples of problems:
  ─ The hospital registered with TrailBlazer under a DBA name:
    “Hospital X”. However, the bank account Tax ID name
    registered in CCR or on the ACH Vendor Enrollment form says
    “Holding Company Y”. This mismatch in names will cause the
    payment to be suspended and will force TrailBlazer Health to
    reprint the remittance advices under the name “Holding
    Company Y” in order for payment to be processed.
  ─ A hospital registered in CCR years ago for a grant opportunity
    under the name: “Hospital X Mammography Department” which
    did not match the banking account Tax ID name: “Hospital X”.

           Payment Process Issues

• Payments and 1099s will come from the Federal Government
 and not TrailBlazer Health.

• Provider organizations should register with TrailBlazer Health
 using the Tax ID name for whatever bank account they
 ultimately want payment made to.

• If your organization already has a CCR profile (and thus an
 ACH Vendor Enrollment form is not necessary), please check
 your CCR profile to make sure that the information is still
 current and matches your desired banking information.

          Payment Process Notes
• Please note that if a lien by any branch of the Federal
 Government has been levied against a provider
 organization, the Treasury Department will
 automatically net this amount out of any ACH
 payment attempted to the provider organization.

• Unfortunately, remittance advices will be mailed to
 providers under separate cover by TrailBlazer Health.
 ASPR/NDMS does not have a mechanism to provide
 this in conjunction with an Electronic Funds Transfer.



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