MCO Encounter Error Solutions General Acute Care and Childrens - PowerPoint PPT Presentation

MCO Encounter Error Solutions General Acute Care and Children’s Hospital Billing Guidelines (P59/P60) Presented 1/26/2017 Updated 1/31/2017

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60) The Illinois Department of Healthcare and Family Services (HFS) requires managed care organizations (MCO) to meet specific claims data submission standards requiring exact data elements on claims submitted from hospitals. To facilitate the appropriate application of these rules, MCOs are collectively relaying information in an effort to reiterate and provide transparency on hospital billing guidelines for services rendered in general acute care and children’s institutional settings. 2

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MEMO TO ALL PROVIDERS FROM IAMHP • http://iamhp.net/resources/Documents/IAMHP%20Memo%20to%20All%20Health – %20Plans.pdf APPENDIX CHART • http://iamhp.net/resources/Documents/Appendix%20A%20General%20Acute%20 – Care%20and%20Children%e2%80%99s%20Billing%20Guidelines%20110116.pdf 4

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http://www.molinahealthcare.com/providers/il/PDF/Medicaid/General-Acute- • Care-Childrens-Hospital-Billing-Guidelines.pdf 6

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60) Documentation usage - Molina Supply to Hospital billing teams for clear definitions of proper allowable Category of Service – (COS) codes, labor and delivery DRG codes, taxonomy codes, and NPI numbers which allows providers to choose age appropriate information at the point of claim entry. (See examples on upcoming slides) – Appendix A grid is a go-to resource/quick reference guide for customer service, UM, provider relations and other internal health plan teams – Molina posts the documentation on its website – Billing Guidelines and Provider Sample Letters have been sent to higher volume P59 and P60 submitters for provider education. (See example letter on next slide) – Quick reference grid assists business analysts with review of claim data elements for proper “root cause” recommendations for correction(s), and is shared with provider relations team for additional provider education – Molina identified 683 P59 Children standalone hospital claims with services for members over 18 years of age, that did not have the correct specialty affiliations through IMPACT/HFS. After updating with IMPACT/HFS these were resubmitted back to HFS as part of EUM metrics and reporting for the measurement period, using the HFS void and replace process Providers that have a Children’s NPI but did not have correct “Children’s” hospital taxonomy – codes were corrected in Molina systems, which reduced P59 errors. Providers that did not have a Children’s NPI and did not have correct “Adult” hospital – taxonomy codes were corrected in Molina systems, which reduced P60 errors 7

Sample Provider Letter 8

General Acute Care and Children’s Hospital Billing Guidelines (P59/P60) Documentation contains all of the following: – General guidance relating to HFS UB-04/837I submissions – List of HFS-registered Children’s hospitals (See next slide) – Allowable inpatient and outpatient categories of services (COS) for institutional NPI billing – Children’s Hospital allowable inpatient and outpatient categories of services (COS) – Labor and delivery DRG usage/guidance – Inpatient Psych and Rehab COS definition – Proper taxonomy usage – Billing for Physical Therapy using Professional NPI – Appendix A grid – All inclusive billing guidelines/Quick reference document 9

HFS Registered Children’s Hospitals 10

General Acute Care and Children Hospital Billing Guidelines (P59/P60) Both General Acute Care and Children’s hospitals are required to register their National Provider Identifier (NPI) numbers as a Provider Type 030 – General Hospital. Psychiatric hospitals are required to register their National Provider Identifier (NPI) numbers as a Provider Type 031, and must use appropriate taxonomy code for the type of service (and bill type) being billed. (For example: Inpatient Psych Services with bill type of 111, at a registered Psychiatric Hospital must bill with the Psychiatric hospital taxonomy code of 283Q00000X on the UB-04 form or 837I format). Rehabilitation hospitals are required to register their National Provider Identifier (NPI) numbers as a Provider Type 032, and must use appropriate taxonomy code for the type of service (and bill type) being billed. (For example: Inpatient Physical rehabilitation with bill type of 111, must bill with the Rehabilitation Hospital taxonomy code of 283X00000X for an adult, and taxonomy code of 283XC2000X for a child, on the UB-04 form or 837I format). Documentation assists billing departments by providing clear rules when HFS billing guidelines are not met, which precipitates the following errors: A38 - Missing/Invalid Taxonomy Code P59 - Care Not Appropriate For Children’s Hospital P60 - Care Not Appropriate For Adult Hospital 11

030 General Hospitals Allowable Categories of Service (COS) 001 Physicians Services ─ ─ 035 Alcohol and Substance Abuse Rehab. 011 Physical Therapy Services ─ Services 012 Occupational Therapy Services ─ ─ 037 Skilled Care Hospital Residing ─ 013 Speech Therapy/Pathology Services ─ 038 Exceptional Care 014 Audiology Services ─ ─ 039 DD/MI Non Acute Care Hospital Residing 017 Anesthesia Services ─ ─ 040 Pharmacy Services (Drug and OTC) 020 Inpatient Hospital Services (General) ─ ─ 041 Medical Equipment/Prosthetic Devices 021 Inpatient Hospital Services (Psychiatric) ─ ─ 048 Medical Supplies ─ 022 Inpatient Hospital Services (Physical ─ 050 Emergency Ambulance Transportation Rehabilitation) ─ 051 Non-Emergency Ambulance Transportation 023 Inpatient Hospital Services (ESRD) ─ ─ 052 Medicar Transportation 024 Outpatient Services (General) ─ ─ 054 Service Car 025 Outpatient Services (ESRD) ─ ─ 067 Maternal & Child Health Application ─ 026 General Clinic Services ─ 068 Mental Health Targeted Case Mgt. Services 027 Psychiatric Clinic Services (Type 'A') ─ for E/I 028 Psychiatric Clinic Services (Type 'B') ─ ─ 069 Subacute Care Program 029 Clinic Services (Physical Rehabilitation) ─ ─ 098 MPE Certification 030 Healthy Kids Services ─ ─ 102 Fluoride Varnish for Children under 36 Months ─ 105 Hospital Presumptive Eligibility 12

031 Psychiatric Hospitals Allowable Categories of Service (COS) – 001 Physicians Services – 010 Nursing Services – 012 Occupational Therapy Services – 013 Speech Therapy/Pathology Services – 014 Audiology Services – 017 Anesthesia Services – 021 Inpatient Hospital Services (Psychiatric) – 024 Outpatient Services (General) – 027 Psychiatric Clinic Services (Type 'A') – 028 Psychiatric Clinic Services (Type 'B') – 035 Alcohol and Substance Abuse Rehab. Services – 037 Skilled Care Hospital Residing – 038 Exceptional Care – 039 DD/MI Non Acute Care Hospital Residing – 040 Pharmacy Services (Drug and OTC) – 041 Medical Equipment/Prosthetic Devices – 048 Medical Supplies – 050 Emergency Ambulance Transportation – 051 Non Emergency Ambulance Transportation – 052 Medicar Transportation – 054 Service Car – 067 Maternal & Child Health Application 13

032 Rehabilitation Hospitals Allowable Categories of Service (COS) – 001 Physicians Services – 010 Nursing Services – 012 Occupational Therapy Services – 013 Speech Therapy/Pathology Services – 014 Audiology Services – 017 Anesthesia Services – 021 Inpatient Hospital Services (Psychiatric) – 024 Outpatient Services (General) – 035 Alcohol and Substance Abuse Rehab. Services – 037 Skilled Care Hospital Residing – 038 Exceptional Care – 039 DD/MI Non Acute Care Hospital Residing – 040 Pharmacy Services (Drug and OTC) – 041 Medical Equipment/Prosthetic Devices – 048 Medical Supplies – 050 Emergency Ambulance Transportation – 051 Non Emergency Ambulance Transportation – 052 Medicar Transportation – 054 Service Car – 067 Maternal & Child Health Application 14

Multiple Unique Institutional NPIs / Shared Single Professional NPI General Acute and Childrens Hospitals Example of hospitals enrolled in the HFS MAP with Multiple Unique Institutional NPIs and a Single Shared Professional NPI: • ABC Hospital and ABC Children’s Hospital Unique General Acute Institutional NPI correlates to Unique Institutional Medicaid ID • All claims for beneficiaries over the age of 18 must be billed using this NPI regardless of services • Labor and delivery (DRG REV 626 or 640) claims must be billed using this NPI and the correct taxonomy • Must select the correct NPI when billing for Inpatient Psych Per Diem Reimbursment Unique Childrens Acute Institutional NPI correlates to Unique Institutional Medicaid ID • General Inpatient Hospital Claims (except Labor and Delivery DRG REV 626 and 640) for children under the age of 18 must be billed using this NPI. Provider must be registered with this specialty in the IMPACT system Shared Professional NPI correlates to Shared Single Professional Medicaid ID  Institutional claims billed on UB-04  Professional claims billed on CMS-1500  Physical Therapy billed on CMS-1500 using the Hospital’s Professional Medicaid ID registered for COS 011.  Since the Professional NPI is shared between both General Acute and Childrens Acute, Provider is able to use the shared NPI to bill Physical Therapy for both adults and children hospitals 15