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Program HH Covered Services

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					 Program HH (HIV/AIDS) Covered Services
 Revised: 09-20-2011


 Recipients may be eligible for Program HH only or other Minnesota Health Care Programs (MHCP), such as medical assistance
 (MA) or General Assistance Medical Care (GAMC), and Program HH.

 Program HH only eligible recipients may have a combination of benefits:

Benefit                      Dental     Mental     Nutrition Case          Drug    MTMS
                                        Health               Mgmt
Basic (DN)                  X           X          X         X                     X
Drug/Insurance/Basic (HI)   X           X          X         X             X       X
Case Management (NT)                                         X
 <br>
 MHCP covers the following benefits for recipients eligible for only Program HH.

 Dental Benefit
 The Program HH dental benefit covers routine diagnostic, preventive, and corrective dental procedures as specified in the MHCP
 Provider Manual’s Dental Services section. In addition, effective January 1, 2010, the following guidelines apply to non-routine
 Program HH dental benefit services:

 Diagnostic
   Comprehensive exam (once every three years, but not within three years of a comprehensive exam covered by MA)
   Periodic exam (once every six months, but not within six months of a periodic exam covered by MA)
   Bitewing x-rays (once a year, unless already covered by MA)
   Periapical x-rays
   Full mouth series (once every four years)
   Panoramic x-ray (once every three years but not within three years of a panoramic x-ray covered by MA, except, if provided in
    conjunction with a scheduled outpatient facility procedure, or as medically necessary for the diagnosis and follow-up of oral
    and maxillofacial pathology and trauma. Once every two years for patients who cannot cooperate for intra-oral film due to a
    developmental disability or medical condition that does not allow for intra-oral film placement)
 <br>
 Preventive
   Prophylaxis
     For recipients eligible for MA, once per six months, but not within six months of a prophylaxis covered by MA
     For recipients eligible for Program HH only, once every six months
     For recipients with pervious history of documented periodontal therapy, may be alternated with a periodontal maintenance
       appointment
  Fluoride varnish (once per year)
  Sealants (recipients through age 18, only first and second permanent molars)
 <br>
 Restorative
  Posterior fillings (paid at the amalgam rate regardless of the material used)
  Anterior fillings
  Crowns (made of prefabricated stainless steel, prefabricated resin, or laboratory resin);
  Endodontics (anterior and premolars endodontics only; authorization is required for molars)
 <br>
 Periodontics
  Scaling and root planing (once every three years) authorization required
  Full mouth debridement (once every five years)
  Periodontal maintenance (once per six months, but not within three months of a prophylaxis covered by MA or HH)
 <br>
 MHCP will deny claims for any combination of the following performed on the same date:
  Adult prophylaxis
  Full mouth debridement
  Periodontal scaling and root planing (four or more teeth per quadrant)
  Periodontal scaling and root planing (1-3 teeth per quadrant)
 <br>
MHCP allows multiple quadrants for periodontal scaling and root planing (four or more teeth per quadrant and 1-3 teeth per
quadrant) on the same day.

Prosthodontics
     Removable appliances (once per arch every three years, but not within three years of a removable appliance provided by
      MA); partial dentures must meet utilization criteria and be prior authorized
 Reline, rebase and repair of removable appliance (may not exceed the cost of new appliance)
<br>
For children through age 20 years, Program HH may consider approving fixed partial dentures (crown & pontics) that meet
utilization criteria and are prior authorized.

Oral Surgery
 Extractions (non-impacted or third molars)
 Biopsies
 Incise & drain
 Splinting (for repositioning a traumatized tooth or stabilizing an alveolar fracture)
<br>
Authorization is required for:
 Extractions for impacted teeth or third molars
 Tooth transplantation
 Placement of device to facilitate eruption of impacted tooth
 Surgical repositioning of teeth
 Transseptal fiberotomy
 Radical resection of maxilla or mandible
 Bone replacement graft for ridge preservation – per site
<br>
Orthodontics
Orthodontic treatment is limited to children through age 20 years, must meet the specifications of utilization criteria and be prior
authorized.

Temporomandibular Joint (TMJ) Disorder
TMJ disorder treatment must meet utilization criteria and be prior authorized:
 Occlusal orthotic appliance
 Unspecified TMD therapy, by report
 All TMJ splints
<br>
Pain Relief
 General anesthesia (for children through age 20 years)
 Palliative treatment
 Sedative fillings
<br>
Dental Billing
Refer to the General Billing Guidelines in the Dental Services (Overview) section for complete billing information.

Providers must review denied claims for recipients with Program HH as services may be reimbursed differently under Program
HH. Refer to the services listed above and those that require authorization in the Program HH Dental Authorization Requirement
Chart for specific coverage details.

Providers must contact Program HH to have their eligible claims reviewed for reimbursement.

Dental Authorization Requirements
If a recipient is eligible for both MA and Program HH, follow MHCP Authorization requirements and submit the authorization to
medical review agent. The medical review agent must receive all required documentation to complete its review. Refer to MHCP
fee-for-service (FFS) Dental Authorization charts below for procedure specific documentation requirements:
 Children and Pregnant Women Authorization Chart
 Limited Benefits Non-Pregnant Adults Authorization Chart
<br>
If the recipient has Program HH only or the dental benefit is limited, refer to the Program HH Dental Authorization Requirement
Chart and submit appropriate documentation to the medical review agent.
Mental Health Benefit
When Program HH recipients do not have mental health insurance coverage or have exhausted their mental health benefits, the
Program HH mental health benefit covers the following limited outpatient services:
 Assessment (90801-90802)
 Individual and group/family/couple therapy).(90804-90815; 90847- 90853)
 Medication management (90862)
 Other (90875, 90887)
<br>
The Program HH mental health benefit does not cover medications, but recipients may be eligible for the Program HH drug
benefit.

Nutrition Benefit
MHCP covers enteral nutritional products when prescribed by a registered dietician for up to $100.00 per calendar month for
recipients approved for the nutritional benefit.

To receive the Program HH nutrition benefit, recipients must first meet with a registered dietician to determine the medical
necessity to receive nutritional supplements.

Registered Dietician Responsibilities
An MHCP-enrolled registered dietician must identify and document the medical necessity for nutritional supplements using the
Nutritional Supplemental Authorization Request (DHS-5849) form. The dietician completes the recipient and dietician information
sections every six months and faxes the form to the dispensing provider. The recipient may also take the form to give to the
dispensing provider.

If the recipient is eligible for MA in addition to the Program HH coverage, submit claims for dietician services to MHCP according
to Licensed Dieticians and Licensed Nutritionists guidelines. If the recipient is eligible for only Program HH, the recipient or
recipient’s private insurance (if any) may be responsible for the dietician services. The recipient may choose a dietician from the
Ryan White funded dieticians if insurance, Medicaid or Medicare do not cover the dietician service.

Dispensing Provider Responsibilities
An MHCP-enrolled medical supplier or pharmacy must request authorization for the Program HH nutritional products from the
Customer Care Specialist. The medical supplier or pharmacy completes the dispensing provider information section of the
Nutritional Supplement Authorization Request form and faxes it to (651) 431-7414 (do not submit these requests to the medical
review agent).

After processing, Program HH will fax the approved or denied authorization request to the medical supplier/pharmacy. MHCP will
issue a follow-up letter to the dispensing provider in the MN–ITS mailbox and send a letter to the recipient.

Billing
To receive Program HH payment for the nutritional products, the dispensing provider must submit the claim(s) as follows:
 Bill using the 837P format
 Enter the approved authorization number (from the approval notice from the Customer Care Specialist)
 Enter the registered dietician’s NPI as the ordering/prescribing provider
 Enter the appropriate diagnosis code(s) that matches the authorization form
<br>
Drug Benefit
The Program HH drug benefit, or AIDS Drug Assistance Program (ADAP), covers the copay for drugs from the Program HH
ADAP formulary for eligible recipients with insurance coverage, and may cover the full cost for the uninsured eligible recipients. If
a drug name appears on the ADAP formulary, but the NDC does not appear in NDC Search or your claim for that drug is denied
as non-covered, call Customer Care at (651) 431-2398 to add the specific NDC.

Insurance Benefit
The Program HH insurance benefit pays an eligible recipient’s medical insurance premium. To qualify, the recipient must pay
more than 51% of the employer-sponsored premium. Medical insurance premiums include, but are not limited to, the following:
 COBRA
 Individually purchased cost effective policies
 Minnesota Comprehensive Health Association (MCHA)
 Recipient portion of employer sponsored insurance (ESI) if the employee pays more than 50% of the premium
Case Management
Program HH funds several clinic and community-based organizations that link Program HH recipients to a variety of services,
such as access to health care coverage, legal services, etc. Case management services are available from agencies specifically
trained in HIV Case Management Standards (PDF). Recipients living with HIV/AIDS who need a case manager may contact
Minnesota AIDSLine at 1-800-248-2437 to find agencies that provide case management.

Medication Therapy Management Services
Effective October 1, 2010 Program HH will cover Medication Therapy Services (MTMS) for Program HH recipients with Basic (DN)
or Basic Plus Drug (HI) coverage. Provider eligibility and privacy space requirement will be the same as the MHCP fee-for-service
(FFS) MTMS requirements. This service is being provided to assist Program HH recipients in understanding the importance of
their drug regiment, issues with adherence, compliance, possible side effects and follow up support.

Eligible Program HH recipients may receive MTMS if they are currently taking or have been prescribed but have not yet started a
medication regiment of any HIV/AIDS antiretroviral medication(s).

Covered Services
MTMS for Program HH includes:
 Obtaining necessary assessments of the recipient’s health status
 Monitoring and evaluating the recipient’s response to the drug therapy, including safety and effectiveness
 Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including
   adverse drug events
 Providing verbal education and training designed to enhance the recipient’s understanding and appropriate use of the
   medications
 Providing information, support services and resources designed to enhance the recipient’s adherence with the recipient’s
   therapeutic regimens
 Formulating a medication treatment/compliance plan
 Documenting the care delivered and communicating essential information to the recipient’s other primary care providers
<br>
Program HH recipients may receive up to 12 MTMS encounters per year. Providers may request authorization for additional
encounters.

An encounter can include:
 Face-to-face encounter, in an area that meets all privacy space requirements and may be provided in:
     Ambulatory care outpatient settings
     Clinics
     Pharmacies
 Telephone encounter, when the call is:
     Initiated by the pharmacist
     Directed to the recipient home phone number on file; the recipient’s file/record must be available to the pharmacist for
       immediate viewing by the pharmacist, throughout the telephone conversation (Program HH will not pay for file/record
       retrieval time)
     Provided in an area that is enclosed enough to prevent other employees or the general public from overhearing the
       conversation
     Documented and kept on file, explaining the need for the telephone contact rather than a face-to-face contact
     Provided in conjunction with at least one face-to-face encounter per year
 Interactive video (ITV) encounter, review MTMS Delivered via Interactive Video
 Home visit, when the face-to-face encounter is:
     Provided in the recipient’s home
     Medically necessary
     Documented with a valid explanation for the reason other MTMS venues were not be in the recipient’s best interest
<br>
Billing
   Submit claims using MN–ITS 837P
   Enter the pharmacist’s NPI number as the treating/rendering provider
   Enter the pharmacy/clinic/hospital MHCP provider NPI number as the pay-to provider
   Use the appropriate MTMS codes (see table below)
   Use modifier GT for ITV encounters
   Use modifier U4 for telephone encounters
   Use place of service 12 for home visit face-to-face encounters
Code     Description                                Unit      Benefit Limit                 Rate
99605    A first encounter performed face-to-face   15 min    1 per 365 days                $52.00
99606    Subsequent follow-up with same recipient   15 min    Up to 11 per 365 days         $34.00
99607    Additional increments for 99605 or 99606   15 min    Up to 4 per date of service   $24.00
<br>
Authorization
If a recipient requires more than the annual 12 MTMS encounters, complete the Program HH MTMS Authorization Request (DHS-
6246) form and fax it to Customer Care at (651) 431-7414 (do not fax to medical review agent).

Legal References
   Ryan White HIV/AIDS Treatment Extension Act of 2009 (Public Law 111-87, October 30, 2009)
   MS 256.9365 Purchase of Continuation Coverage for AIDS Patients.
   MS 256.01, subds. 18, 19, 20 State authority for HIV/AIDS

Additional Resources
HIV/AIDS program (Disabilities) page
HIV/AIDS page

				
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