Pediatric Flu Vaccine: Special Situations
In the event a Medicaid provider does not have VFC pediatric influenza vaccine on hand tovaccinate a high priority VFC eligible Medicaid enrolled child, the provider should use pediatric influenza vaccine from private stock, if available. If a provider does use vaccine from private stock for a high priority VFC eligible Medicaid enrolled child, the provider would then replace dose(s) used from private stock with replacement dose(s) from VFC stock when VFC vaccine becomes available. The provider should not turn away, refer or reschedule a high priority VFC eligible Medicaid enrolled child for a later date if vaccine is available. Louisiana Medicaid will update Medicaid enrolled providers through remittance advices and the Louisiana Medicaid Provider Update regarding availability of vaccine through the VFC program and any billing issues. Please contact the Louisiana VFC Program office at (504)838-5300 for vaccine availability information.
* indicates the vaccine is available from the Vaccines For Children (VFC) program
^ indicates the vaccine is payable for QMB Only and QMB Plus recipients Vaccine
Code Description
90476^ Adenovirus vaccine, type 4, live, for oral use
90477^ Adenovirus vaccine, type 7, live, for oral use
90581^ Anthrax vaccine, for subcutaneous use
90585 Bacillus Calmette-Guerin vaccine (BCG) for tuberculosis, live, for percutaneous use
90586 Bacillus Calmette-Guerin vaccine (BCG) for bladder cancer, live, for intravesical use
90632 Hepatitis A vaccine, adult dosage, for intramuscular use
90633* Hepatitis A vaccine pediatric/adolescent dosage, 2-dose schedule, for intramuscular use
90634* Hepatitis A vaccine, pediatric/adolescent dosage, 3-dose schedule, for intramuscular use
90636 Hepatitis A and Hepatitis B vaccine (HepA-HepB), adult dosage, for intramuscular use
90645 Hemophilus influenza b vaccine (Hib), HbOC conjugate (4 dose schedule), for intramuscular use
90646 Hemophilus Influenza b vaccine (Hib), PRP-D conjugate, for booster use only, intramuscular use
90647* Hemophilus influenza b vaccine (Hib), PRP-OMP conjugate (3 dose schedule), for intramuscular use
90648* Hemophilus influenza b vaccine (Hib), PRP-T conjugate (4 dose schedule), for intramuscular use
90649* Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular use
90655* Influenza virus vaccine, split virus, preservative free, when administered to children 6-35 months of age, for
intramuscular use
90656* Influenza virus vaccine, split virus, preservative free, when administered to 3 years and older, for intramuscular use
90657* Influenza Virus vaccine, split virus, when administered to children 6-35 months of age, for intramuscular use
90658* Influenza Virus vaccine, split virus, when administered to 3 years of age and older, for intramuscular use
90660* Influenza Virus vaccine, live, for intranasal use
90665^ Lyme Disease vaccine, adult dosage, for intramuscular use
90669* Pneumococcal conjugate vaccine, polyvalent, when administered to children younger than 5 years, for intramuscular use
90675^ Rabies vaccine, for intramuscular use
90676^ Rabies vaccine, for intradermal use
90680* Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral use
90690^ Typhoid vaccine, live, oral
2007 Louisiana Medicaid Professional Services Provider Training 100
Vaccine Codes
Code Description
90691^ Typhoid vaccine, Vi capsular polysaccharide (ViCPS), for intramuscular use
90692^ Typhoid vaccine, heat-and phenol-inactivated (H-P) for subcutaneous or intradermal use
90693 Typhoid vaccine, acetone-killed, dried (AKD), for subcutaneous use (US Military)
90698 Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated, (DTaP-Hib-IPV), for intramuscular use
90700 * Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to younger than 7 years, for intramuscular use
90701 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine (DTP), for intramuscular use
90702* Diphtheria and tetanus toxoids (DT) absorbed when administered to younger than 7 years, for intramuscular use
90703 Tetanus toxoid adsorbed, for intramuscular use
90704 Mumps virus vaccine, live, for subcutaneous use
90705 Measles virus vaccine, live, for subcutaneous use
90706 Rubella virus vaccine, live, for subcutaneous use
90707* Measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous
90708 Measles and rubella virus vaccine, live, for subcutaneous use
90710* Measles, mumps, rubella, and varicella vaccine (MMRV), live, for subcutaneous use
90712 Poliovirus vaccine, (any type(s)) (OPV), live, for oral use
90713* Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular use
90714* Tetanus and diphtheria toxoids, (Td) absorbed, preservative free, when administered to 7 years or older, for intramuscular use
90715* Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to 7 years or older, for
intramuscular use
90716* Varicella virus vaccine, live, for subcutaneous use
90717 Yellow fever vaccine, live, for subcutaneous use
90718* Tetanus and diphtheria toxoids (Td) adsorbed when administered to7 years or older, for intramuscular use
90719 Diphtheria toxoid, for intramuscular use
90720 Diphtheria, tetanus toxoids, and whole cell pertussis vaccine and Hemophilus influenza B vaccine (DTP-Hib), for intramuscular use
90721* Diphtheria, tetanus toxoids, and acellular pertussis vaccine and Hemophilus influenza B vaccine (DTaP-Hib), for intramuscular use
90723* Diphtheria, tetanus toxoids, acellular pertussis vaccine, Hepatitis B, and poliovirus vaccine, inactivated (DTaP-HepB-IPV), for intramuscular use
90725 Cholera vaccine for injectable use
90727 Plague vaccine, for intramuscular use
90732 Pneumococcal polysaccharide vaccine, 23-valent, adult or immunosuppressed patient dosage, when administered to 2 years or older, for subcutaneous or intramuscular use
90733 Meningococcal polysaccharide vaccine (any group(s)), for subcutaneous use
90734* Meningococcal conjugate vaccine, serogroups A, C, Y and W-135 (tetravalent), for
2007 Louisiana Medicaid Professional Services Provider Training 101
Vaccine Codes
* indicates the vaccine is available from the Vaccines For Children (VFC) program
^ indicates the vaccine is payable for QMB Only and QMB Plus recipients
90735 Japanese Encephalitis Virus vaccine, for subcutaneous use
90736 Zoster (shingles) vaccine, live, for subcutaneous injection
90740 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (3 dose schedule), for intramuscular use
90743 Hepatitis B vaccine, adolescent (2 dose schedule), for intramuscular use
90744* Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90746* Hepatitis B vaccine, adult dosage, for intramuscular use
90747 Hepatitis B vaccine, dialysis or immunosuppressed patient dosage (4 dose schedule), for intramuscular use
90748* Hepatitis B and Hemophilus influenza b vaccine (HepB-Hib), for intramuscular use
• Procedure code 90703 (Tetanus toxoid - for trauma) will be payable at the rate of $2.42, and it is not available through the VFC program.
• If the administration units for 90466, 90468, 90472 or 90474 are greater than the number of vaccines reported for the administration codes, the units will be cutback to reflect the number of vaccine codes being reported.
• If the administration units for 90466, 90468, 90472 or 90474 are less than the number of vaccines reported the claim will be processed based on the units listed for administration.
Showing posts with label medicaid. Show all posts
Showing posts with label medicaid. Show all posts
Medicaid increases the payment of Pediatric
Pediatric Physician Rate Increase
Effective January 1, 2015, Current Procedural Terminology (CPT®) codes 99201 through 99496 will be reimbursed with an enhanced rate to pediatric physicians billing fee-for-service with one of the following specialty codes: 001, 019, 023 035, 036, 037, 038, 039, 043, 049, 059, 101,102. The Physician Evaluation and Management Fee Schedule will be amended to reflect this change.
Providers receiving reimbursement through a Medicaid managed care plan should refer to their contract with each plan to determine whether this change will impact their reimbursement from the plan.
Can we submit the claim if patient has provided the backdated card , what is the time limit for secondary claims
Backdated Medicaid Cards
If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card. Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.
Example: Services rendered by a physician on 3/1/2012; on 6/1/2012, member‟s Medicaid eligibility is granted effective 3/1/2012. All services previously rendered after 3/1/2012 can be billed to Medicaid, and considered for reimbursement if claims are received by 6/1/2013.
MCO‟s and Timely Filing
Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible. In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service. Please Note: The MCO must be one of the MCO‟s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.
To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical card.)
The original claim must have had the following valid information:
• Valid provider number
• Valid member number
• Valid date of service
• Valid type of bill
Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.
This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing.
Medicare Primary Claims/Secondary Claims
Timely filing requirement for Medicare primary claims is one year from the EOMB date. Did you know that secondary claims can be submitted electronically? For more information, please call our EDI help desk at 888-483-0793, option 6.
If a member receives a backdated medical card and the provider wishes to accept it and bill Medicaid for services that occurred over a year ago, the claims must be billed within one year of the issuance of the card. Claims must be billed on paper with a copy of the medical card or letter of eligibility and mailed to Provider Relations address at PO Box 2002, Charleston, WV 25327-2002.
Example: Services rendered by a physician on 3/1/2012; on 6/1/2012, member‟s Medicaid eligibility is granted effective 3/1/2012. All services previously rendered after 3/1/2012 can be billed to Medicaid, and considered for reimbursement if claims are received by 6/1/2013.
MCO‟s and Timely Filing
Molina does not reimburse for any services the provider does not bill timely to the MCO. If the MCO denial is due to the member not being covered under the MCO and the provider determines that the member was covered with WV Medicaid at the time services were rendered, Molina may be responsible. In this case, Molina will accept MCO Medicaid remits as proof of timely filing as long as the date of the denial is not over a year from the date of service. Please Note: The MCO must be one of the MCO‟s that are contracted with WV Medicaid and not an MCO that has a private insurance policy for the member.
To meet timely filing requirements for WV Medicaid, claims must be received within one year from the date of service. The year is counted from the date of receipt to the “from date” on a CMS 1500, Dental or UB04. Claims that are over one year old must have been billed and received within the one year filing limit. (See exceptions below for Medicare primary claims and backdated medical card.)
The original claim must have had the following valid information:
• Valid provider number
• Valid member number
• Valid date of service
• Valid type of bill
Claims that are over one year old must be submitted with a copy of the remittance advice showing where the claim was received prior to turning a year old. Claims with dates of service over two years old are NOT eligible for reimbursement.
This policy is applicable to reversal/replacement claims. If a reversal/replacement claim is submitted with a date of service that is over one year old, the replacement claim must be billed on paper with a copy of the original remittance advice to: Provider Relations, PO Box 2002, Charleston, WV 25327-2002. You are NOT allowed to add additional services to the replacement claim. If additional services are billed on the replacement claim that were not billed on the original claim and the dates of service are over one year old, the claim will be denied for timely filing.
Medicare Primary Claims/Secondary Claims
Timely filing requirement for Medicare primary claims is one year from the EOMB date. Did you know that secondary claims can be submitted electronically? For more information, please call our EDI help desk at 888-483-0793, option 6.
How much is Medicaid copay - out of pocket and what are the exemption cases
Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid Members. The following copays will apply to claims with a date of service on or after January 1, 2014:
Service TIER 1 Up to 50.00% FPL TIER 2 50.01-100.00% FPL TIER 3 100.01% FPL and above
Inpatient Hospital (Acute Care 11x) --- $0 $35 $75
Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care) --- $0 $2 $4
Non-Preferred Drugs ---- $2 $4 $8
Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) ---------- $8 $8 $8
Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0 $2 $4
Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.
Tier Level Out of Pocket Maximum
1 (Up to 50.00% FPL) $8
2 (50.01-100.00% FPL) $71
3 (100.01% FPL and above) $143
Quarters
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014
Exemptions:
The following populations and services are exempt from copays:
Pregnant Women including pregnancy-related services up to 60 days post-partum;
Children under age 21;
Native American and Alaska natives;
Intermediate Care Facility or MR services;
Preventive services for children under age 18;
Provider-preventable services;
Individuals in Nursing Homes,
Receiving Hospice services,
Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.
Service TIER 1 Up to 50.00% FPL TIER 2 50.01-100.00% FPL TIER 3 100.01% FPL and above
Inpatient Hospital (Acute Care 11x) --- $0 $35 $75
Office Visit (Physicians and Nurse Practitioners) (99201-99205, 99212-99215 only for office visits for new and established patients based on level of care) --- $0 $2 $4
Non-Preferred Drugs ---- $2 $4 $8
Non-Emergency use of Emergency Department - Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of this visit is an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.) ---------- $8 $8 $8
Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms. --- $0 $2 $4
Maximum Out of Pocket (OOP):
Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.
Tier Level Out of Pocket Maximum
1 (Up to 50.00% FPL) $8
2 (50.01-100.00% FPL) $71
3 (100.01% FPL and above) $143
Quarters
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014
Exemptions:
The following populations and services are exempt from copays:
Pregnant Women including pregnancy-related services up to 60 days post-partum;
Children under age 21;
Native American and Alaska natives;
Intermediate Care Facility or MR services;
Preventive services for children under age 18;
Provider-preventable services;
Individuals in Nursing Homes,
Receiving Hospice services,
Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program;
Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.
How to File a Void Request on a Paper Claim
Requirements for Filing a Void Request
A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.
Voiding Claims on the Remittance Voucher
A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.
Voiding Claims on a Paper Claim Form
When requesting a void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed on following page;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and
· Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080
A void request will be processed as a replacement to the original, incorrectly paid claim. When a claim is voided, the total payment for the original claim is deducted. There is no time limit on submitting a void. The provider can submit a paper void request on the remittance voucher, a legible photocopy of the
original claim, or an entirely new claim.
Voiding Claims on the Remittance Voucher
A claim can be voided by photocopying the remittance voucher and in black ink circling the claim to be voided. Write “void” on the side of the remittance voucher and briefly explain why the void is requested. Sign and date the remittance voucher in the margin. Only one claim can be voided per copy of the remittance voucher. Additional claims on the same remittance voucher must be voided by submitting additional photocopies of the remittance voucher. Each copy of the remittance voucher can only have one claim circled on it.
Voiding Claims on a Paper Claim Form
When requesting a void, the provider must:
· Resubmit a photocopy of the original claim or a new claim form;
· Enter the items listed on following page;
· Initial and date the form if it is a photocopy, or sign and date it if it is a new
form; and
· Mail the void request to the fiscal agent for processing to:
Adjustments and Voids
P.O. Box 7080
Tallahassee, Florida 32314-7080
How to Resubmit a Denied Claim
Instructions
Check the remittance voucher before submitting a second request for payment. Claims may be resubmitted for one of the following reasons only:
· The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
· The claim was denied due to incorrect or missing information or lack of a required attachment.
Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.
No Response Received
If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:
· Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.
· If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.
· If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.
Correcting a Denied Claim
If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.
Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.
* Did you wait thirty days after the original submittal before resubmitting a missing claim?
* If using a photocopy of a claim, did you make sure it was legible and properly aligned?
* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?
* If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)
* Have you clipped all required attachments and documentation to the claim form?
* Is the claim clean of all highlighting and whiteout?
* Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?
Check the remittance voucher before submitting a second request for payment. Claims may be resubmitted for one of the following reasons only:
· The claim has not appeared on a remittance voucher as paid, denied, or suspended for thirty days after it was submitted; or
· The claim was denied due to incorrect or missing information or lack of a required attachment.
Do not resubmit a claim denied because of Medicaid program limitations or policy regulations. Computer edits ensure that it will be denied again.
No Response Received
If the claim does not appear on a remittance voucher within 30 days of the day it was mailed, the provider should take the following steps:
· Check recently received remittance voucher dates. Look for gaps. A remittance voucher may have been mailed but lost in transit. If the provider believes this is the case, call ACS Provider Inquiry.
· If there is not a gap in the dates of remittance vouchers received, please call the Medicaid fiscal agent, Provider Inquiry. An associate will research the claim.
· If the fiscal agent advises that the claim was never received, please resubmit another claim immediately. See the Resubmission Checklist on the following page in this chapter.
Correcting a Denied Claim
If the claim has been denied for incorrect or missing information, correct the errors before resubmitting the claim.
Resubmission Checklist
Use the following checklist to ensure that resubmittals are completed correctly before submitting.
* Did you wait thirty days after the original submittal before resubmitting a missing claim?
* If using a photocopy of a claim, did you make sure it was legible and properly aligned?
* If you chose to fill out a new claim, did you type or print the form in black ink? Are all multi-part copies legible?
* If you have corrected or changed the original claim form, have strikeovers been corrected on each copy? (Do not use whiteout.)
* Have you clipped all required attachments and documentation to the claim form?
* Is the claim clean of all highlighting and whiteout?
* Do you have the correct P.O. Box Number and corresponding nine-digit zip code for mailing the resubmitted claim?
what is Remittance Voucher
Description
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
The remittance voucher displays the disposition of all claims processed during the claims cycle. A remittance voucher is mailed each week if the fiscal agent processed any claims or put any claims in “Suspend” status. If the provider receives payment by paper check, the check is mailed separately.
Role of the Remittance Voucher
The remittance voucher plays an important role in communications between the provider and Medicaid. It tells what happened to the claims submitted for payment–whether they were paid, suspended, or denied. It provides a record of transactions and assists the provider in resolving errors so that denied claims can be resubmitted.
The provider must reconcile the remittance voucher with the claim in order to determine if correct payment was received.
The remittance voucher contains one or more of the following sections, depending on the type of claims filed, the disposition of those claims, and any new billing or policy announcements:
· Remittance Voucher Banner Page Message
· Disposition Category by Groups
· Summary Section
Remittance Voucher Banner Page Message
When Medicaid or the fiscal agent discovers billing problems encountered by all or selected provider types, a remittance voucher banner message is printed as the first page of the voucher. Suggestions for avoiding problems, explanations of policy, and new or changed procedure codes are described. Training sessions
are also announced on the remittance voucher banner page.
Disposition Category by Groups
Claims are listed by disposition category (paid, denied, or suspended) in alphabetical order by the recipient’s last name. Voids and adjustments are also listed separately.
Suspend Status
All claims in the “Suspend” status are reported each week until adjudicated as “Paid” or “Denied.” If one line on a claim form suspends, then the entire claim will suspend until all of the claim lines can be adjudicated.
Summary Section
The remittance voucher summary section reports the number of claim transactions, and the total payment or check amount. If the account shows a prior negative balance, it will be carried forward weekly until eliminated.
Insurance Claims Processing cycel - different stage
Paper Claim Handling
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
When the Medicaid fiscal agent receives a paper claim, it is screened for missing information and necessary attachments. If information or documentation is missing, the claim will not be entered into the Florida Medicaid Management Information System (FMMIS). It will be returned to the provider with a Return to Provider (RTP) letter that will state the reason the claim is being returned. The provider needs to correct the error, attach any missing documentation, and return the claim to the fiscal agent for processing.
Claim Entry
Data entry operators image and key into FMMIS each paper claim that passes initial screening. Electronic claims are loaded by batch into FMMIS by the fiscal agent’s data processing staff.
Claim Adjudication
FMMIS analyzes the claim information and determines the status or disposition of the claim. This process is known as claim adjudication.
Disposition of Claim
A claim disposition can be:
· Paid: payment is approved in accordance with program criteria.
· Suspended: the claim is put on “hold” so it can be analyzed in more detail by the fiscal agent or AHCA Medicaid.
· Denied: payment cannot be made because the information supplied indicates the claim does not meet program criteria, or information necessary for payment was either erroneous or missing.
Processing Time Frames
Claims are processed daily. Payments are made on a weekly basis. Under normal conditions a claim can be processed from receipt to payment within 7 to 30 days.
List of all place of service with description
Place of Service Codes (POS)
03 School
A school facility where a recipient receives a Medicaid service. This new place of service is effective with HIPAA implementation.
11 Office
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, intermediate care facility (ICF), or mobile van where the health professional routinely provides health examination, diagnosis and treatment of illness or injury on an ambulatory basis.
12 Patient’s Home
Location, other than a hospital or other facility, where the patient receives care in a private residence.
13 Assisted Living Facility
Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.
14 Group Home
Congregate residential foster care setting for children and adolescents in state custodythat provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community.
21 Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non surgical) and rehabilitation services, by or under the supervision of physicians, to patients admitted for a variety of medical conditions.
22 Outpatient Hospital
A portion of a hospital that provides diagnostic, therapeutic (both surgical and non surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23 Emergency Room - Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided on a 24-hour basis.
24 Ambulatory Surgical Center
A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
25 Birthing Center
A facility, other than a hospital’s maternity facilities or a physician’s office, that provides a setting for labor, delivery and immediate postpartum care as well as immediate care of newborn infants.
31 Skilled Nursing Facility
A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital.
32 Nursing Facility
A facility that primarily provides residents with skilled nursing care and related services for rehabilitation of an injured, disabled, or sick person; or on a regular basis, healthrelated care services above the level of custodial care to other than mentally retarded individuals.
33 Custodial Care Facility
A facility that provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34 Hospice
A facility other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
Note: This place of service can only be used when the actual service is performed in a hospice facility. If a hospice patient receives services in a setting other than a hospice facility, then the specific location for that service must be used.
49 Independent Clinic
A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
51 Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. This place of service code is only used for Medicare crossover billing.
53 Community Mental Health Center
A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area.
54 Intermediate Care Facility for the Developmentally Disabled (IFC-DD)
A facility that primarily provides health-related care and services above the level of custodial care to developmentally disabled individuals, but does not provide the level of care or treatment available in a hospital or a skilled nursing facility.
55 Residential Substance Abuse Treatment Facility
A facility that provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
57 Non-residential Substance Abuse Treatment Facility
A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
62 Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities.
65 End Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment, and maintenance or training to patients or caregivers.
71 State or Local Public Health Clinic
A facility maintained by either state or local health departments that provides ambulatory primary care under the general direction of a physician.
72 Rural Health Clinic or Federally Qualified Health Center
A certified facility located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
A certified facility located in a medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
81 Independent Laboratory
A laboratory certified to perform diagnostic or clinical tests independent of an institution or a physician’s office.
99 Other Unlisted Facility
Other service facilities not identified above.
03 School
A school facility where a recipient receives a Medicaid service. This new place of service is effective with HIPAA implementation.
11 Office
Location, other than a hospital, skilled nursing facility (SNF), military treatment facility, community health center, state or local public health clinic, intermediate care facility (ICF), or mobile van where the health professional routinely provides health examination, diagnosis and treatment of illness or injury on an ambulatory basis.
12 Patient’s Home
Location, other than a hospital or other facility, where the patient receives care in a private residence.
13 Assisted Living Facility
Congregate residential facility with self-contained living units providing assessment of each resident’s needs and on-site support 24 hours a day, 7 days a week, with the capacity to deliver or arrange for services including some health care and other services.
14 Group Home
Congregate residential foster care setting for children and adolescents in state custodythat provides some social, health care, and educational support services and that promotes rehabilitation and reintegration of residents into the community.
21 Inpatient Hospital
A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and non surgical) and rehabilitation services, by or under the supervision of physicians, to patients admitted for a variety of medical conditions.
22 Outpatient Hospital
A portion of a hospital that provides diagnostic, therapeutic (both surgical and non surgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
23 Emergency Room - Hospital
A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided on a 24-hour basis.
24 Ambulatory Surgical Center
A freestanding facility, other than a physician’s office, where surgical and diagnostic services are provided on an ambulatory basis.
25 Birthing Center
A facility, other than a hospital’s maternity facilities or a physician’s office, that provides a setting for labor, delivery and immediate postpartum care as well as immediate care of newborn infants.
31 Skilled Nursing Facility
A facility that primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services, but does not provide the level of care or treatment available in a hospital.
32 Nursing Facility
A facility that primarily provides residents with skilled nursing care and related services for rehabilitation of an injured, disabled, or sick person; or on a regular basis, healthrelated care services above the level of custodial care to other than mentally retarded individuals.
33 Custodial Care Facility
A facility that provides room, board and other personal assistance services, generally on a long-term basis, and which does not include a medical component.
34 Hospice
A facility other than a patient’s home, in which palliative and supportive care for terminally ill patients and their families are provided.
Note: This place of service can only be used when the actual service is performed in a hospice facility. If a hospice patient receives services in a setting other than a hospice facility, then the specific location for that service must be used.
49 Independent Clinic
A location, not part of a hospital and not described by any other Place of Service code, that is organized and operated to provide preventive, diagnostic, therapeutic, rehabilitative, or palliative services to outpatients only.
51 Inpatient Psychiatric Facility
A facility that provides inpatient psychiatric services for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician. This place of service code is only used for Medicare crossover billing.
53 Community Mental Health Center
A facility that provides comprehensive mental health services on an ambulatory basis primarily to individuals residing or employed in a defined area.
54 Intermediate Care Facility for the Developmentally Disabled (IFC-DD)
A facility that primarily provides health-related care and services above the level of custodial care to developmentally disabled individuals, but does not provide the level of care or treatment available in a hospital or a skilled nursing facility.
55 Residential Substance Abuse Treatment Facility
A facility that provides treatment for substance (alcohol and drug) abuse to live-in residents who do not require acute medical care. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, psychological testing, and room and board.
57 Non-residential Substance Abuse Treatment Facility
A location that provides treatment for substance (alcohol and drug) abuse on an ambulatory basis. Services include individual and group therapy and counseling, family counseling, laboratory tests, drugs and supplies, and psychological testing.
62 Comprehensive Outpatient Rehabilitation Facility
A facility that provides comprehensive rehabilitation services under the supervision of a physician to outpatients with physical disabilities.
65 End Stage Renal Disease Treatment Facility
A facility other than a hospital, which provides dialysis treatment, and maintenance or training to patients or caregivers.
71 State or Local Public Health Clinic
A facility maintained by either state or local health departments that provides ambulatory primary care under the general direction of a physician.
72 Rural Health Clinic or Federally Qualified Health Center
A certified facility located in a rural medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
A certified facility located in a medically underserved area that provides ambulatory primary medical care under the general direction of a physician.
81 Independent Laboratory
A laboratory certified to perform diagnostic or clinical tests independent of an institution or a physician’s office.
99 Other Unlisted Facility
Other service facilities not identified above.
Basic rules for submitting clean claim - Medicaid
Basic Rules for Completing Blank Non-Institutional 081 Claim Forms
There are some basic rules to follow before completing the claim form.
· Make sure the Non-Institutional 081 is the right form to use for the claim.
· Enter all information using black type or a pen using black ink. (The fiscal agent can only process clean claims with black type or ink. Use only black ink on adjusted claims to indicate the item being corrected.)
· Be sure the information on the form is legible.
· Enter information within the allotted spaces.
· Do not use whiteout.
· Complete the form using the service-specific Coverage and Limitations Handbook as a reference
Before Completing the Form
Before filling out a claim form, answer the following questions:
· Was the recipient eligible for Medicaid on the date of service?
· Has the recipient’s eligibility been verified?
· Was a MediPass or HMO authorization obtained, if applicable?
· Was the service or item covered by Medicaid?
· Was the service in the recipient’s plan of care?
· Was the case manager’s authorization obtained, if applicable?
· Has a claim been filed, and a response received, for all other insurance held by the recipient?
If all of the above information is not available, review the instructions in this handbook.
If the response to all of the above questions is “yes,” fill out the claim form following the step-by-step instructions for each item on the form.
Recipient’s Name
Enter the recipient’s last name, first name, and middle initial exactly as it appears on the gold, plastic Medicaid identification (ID) card or other proof of eligibility
Medicaid Identification Number
Enter the recipient’s ten-digit Medicaid ID number. Do not enter the number on the Medicaid ID card. This is a card control number, not the recipient’s Medicaid ID number.
There are some basic rules to follow before completing the claim form.
· Make sure the Non-Institutional 081 is the right form to use for the claim.
· Enter all information using black type or a pen using black ink. (The fiscal agent can only process clean claims with black type or ink. Use only black ink on adjusted claims to indicate the item being corrected.)
· Be sure the information on the form is legible.
· Enter information within the allotted spaces.
· Do not use whiteout.
· Complete the form using the service-specific Coverage and Limitations Handbook as a reference
Before Completing the Form
Before filling out a claim form, answer the following questions:
· Was the recipient eligible for Medicaid on the date of service?
· Has the recipient’s eligibility been verified?
· Was a MediPass or HMO authorization obtained, if applicable?
· Was the service or item covered by Medicaid?
· Was the service in the recipient’s plan of care?
· Was the case manager’s authorization obtained, if applicable?
· Has a claim been filed, and a response received, for all other insurance held by the recipient?
If all of the above information is not available, review the instructions in this handbook.
If the response to all of the above questions is “yes,” fill out the claim form following the step-by-step instructions for each item on the form.
Recipient’s Name
Enter the recipient’s last name, first name, and middle initial exactly as it appears on the gold, plastic Medicaid identification (ID) card or other proof of eligibility
Medicaid Identification Number
Enter the recipient’s ten-digit Medicaid ID number. Do not enter the number on the Medicaid ID card. This is a card control number, not the recipient’s Medicaid ID number.
claims not submitted within the time limit - exceptional scenrio
Exceptions to the 12-Month Time Limit
Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:
· New clean claim submitted within six months of the date of the void of the original claim payment date;
· Court or hearing decision;
· Delay in recipient eligibility determination;
· Medicaid delay in updating eligibility file;
· Court ordered or statutory action; or
· System error on a claim that was originally filed within 12 months from the date of service.
Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent. Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six months from the void date.
Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.
Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
· A clean claim,
· A copy of the recipient’s proof of eligibility, and
· Documentation of the reason for late submission.
Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.
Court Ordered or Statutory Action
If the Medicaid office takes corrective action due to a court order or due to final agency action taken under Chapter 120, Florida Statutes, there is no time limit for claim submission.
System Error
If a clean claim is denied due to a system error or any error that is the fault of Medicaid or the fiscal agent, an exception may be granted if the provider submits another clean claim along with documentation of the denial to the area Medicaid office no later than 12 months from the date of the original denial.
Evaluate the Claim
The provider must evaluate any claim that is denied and determine if the claim fits any of the conditions for an exception to the 12-month filing limit.
Exceptions to the 12-month claim submission time limit may be allowed if the claim meets one or more of the following conditions:
· New clean claim submitted within six months of the date of the void of the original claim payment date;
· Court or hearing decision;
· Delay in recipient eligibility determination;
· Medicaid delay in updating eligibility file;
· Court ordered or statutory action; or
· System error on a claim that was originally filed within 12 months from the date of service.
Any claim filed more than 12 months from the date of service that meets an exception must be sent to the area Medicaid office for processing, not to the fiscal agent. Each of these exceptions is discussed below.
Original Payment is Voided
When an original Medicaid claim is voided, the provider may submit a new claim and a written request for assistance to the area Medicaid office no later than six months from the void date.
Court or Hearing Decision
When a recipient is approved for Medicaid as a result of a fair hearing or court decision, there is no time limit for the submission of a claim.
Delay in Recipient Eligibility Determination
An exception may be granted when there is a delay in the determination of an individual’s Medicaid eligibility by the Department of Children and Families or the Social Security Administration. The provider must send in specific documentation to the area Medicaid office no later than 12 months from the date the recipient’s eligibility is updated on FMMIS. The claim submission must
include:
· A clean claim,
· A copy of the recipient’s proof of eligibility, and
· Documentation of the reason for late submission.
Medicaid Delay in Updating Eligibility File
If Medicaid delays updating a recipient’s eligibility on the Florida Medicaid Management Information System (FMMIS), an exception may be granted. The provider must submit the related clean claims to the area Medicaid office no later than 12 months from the date the recipient’s eligibility file was updated.
Court Ordered or Statutory Action
If the Medicaid office takes corrective action due to a court order or due to final agency action taken under Chapter 120, Florida Statutes, there is no time limit for claim submission.
System Error
If a clean claim is denied due to a system error or any error that is the fault of Medicaid or the fiscal agent, an exception may be granted if the provider submits another clean claim along with documentation of the denial to the area Medicaid office no later than 12 months from the date of the original denial.
Evaluate the Claim
The provider must evaluate any claim that is denied and determine if the claim fits any of the conditions for an exception to the 12-month filing limit.
Medicaid - clean claim, time limit for secondary claim and claim received date
Timely Claim Submission
Medicaid providers should submit claims immediately after providing services so that any problems with a claim can be corrected and the claim resubmitted before the filing deadline.
A clean claim for services rendered must be received by the Medicaid office or its fiscal agent no later than 12 months from the date of service
Clean Claim
In order for a claim to be paid, it must be a clean claim. A clean claim is a Medicaid claim that:
· Has been accurately and fully completed according to Medicaid billing guidelines.
· Is accompanied by all necessary documentation.
· Can be processed and adjudicated by the fiscal agent without obtaining additional information from the provider.
Date Received Determined
The date stamped on the claim by any Medicaid office or by the Medicaid fiscal agent is the recorded date of receipt for a paper claim. The fiscal agent date stamps the claim the date that it is received in the fiscal agent’s mailroom.
The date electronically coded on the provider’s electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.
Third Party Payer and Medicare Insurance Claims
Claims for recipients who have Medicare or other insurance must be submitted to a third party payer prior to sending the claim to Medicaid.
For non-Medicare claims, the claim must be received by Medicaid or the Medicaid fiscal agent no later than 12 months from the date of service or six months from the date of the other insurance payment or denial.
The filing limit for Medicare claims crossing over to Medicaid is the greater of 36 months from the date of discharge or 12 months from Medicare’s adjudication date.
Medicaid providers should submit claims immediately after providing services so that any problems with a claim can be corrected and the claim resubmitted before the filing deadline.
A clean claim for services rendered must be received by the Medicaid office or its fiscal agent no later than 12 months from the date of service
Clean Claim
In order for a claim to be paid, it must be a clean claim. A clean claim is a Medicaid claim that:
· Has been accurately and fully completed according to Medicaid billing guidelines.
· Is accompanied by all necessary documentation.
· Can be processed and adjudicated by the fiscal agent without obtaining additional information from the provider.
Date Received Determined
The date stamped on the claim by any Medicaid office or by the Medicaid fiscal agent is the recorded date of receipt for a paper claim. The fiscal agent date stamps the claim the date that it is received in the fiscal agent’s mailroom.
The date electronically coded on the provider’s electronic transmission by the Medicaid fiscal agent is the recorded date of receipt for an electronic claim.
Third Party Payer and Medicare Insurance Claims
Claims for recipients who have Medicare or other insurance must be submitted to a third party payer prior to sending the claim to Medicaid.
For non-Medicare claims, the claim must be received by Medicaid or the Medicaid fiscal agent no later than 12 months from the date of service or six months from the date of the other insurance payment or denial.
The filing limit for Medicare claims crossing over to Medicaid is the greater of 36 months from the date of discharge or 12 months from Medicare’s adjudication date.
Cost Sharing Out of Pocket Costs-NC Medicaid
Out of Pocket Costs
States can impose copayments, coinsurance, deductibles, and other similar charges on most Medicaid-covered benefits, both inpatient and outpatient services, and the amounts that can be charged vary with income. All out of pocket charges are based on the individual state’s payment for that service.Out of pocket costs cannot be imposed for emergency services, family planning services, pregnancy-related services, or preventive services for children. Generally, out of pocket costs apply to all Medicaid enrollees except those specifically exempted by law and most are limited to nominal amounts. Exempted groups include children, terminally ill individuals, and individuals residing in an institution. Because Medicaid covers particularly low-income and often very sick patients, services cannot be withheld for failure to pay, but enrollees may be held liable for unpaid copayments.
States have the option to establish alternative out of pocket costs. These charges may be targeted to certain groups of Medicaid enrollees with income above 100 percent of the federal poverty level. Alternative out of pocket costs may be higher than nominal charges depending on the type of service, and they are subject to a cap not exceeding 5 percent of family income. In addition, Medicaid enrollees may be denied services for nonpayment of alternative copayments.
Maximum Nominal Out of Pocket Costs
Cost sharing for most services is limited to nominal or minimal amounts. The maximum copayment that Medicaid may charge is based on what the state pays for that service, as described in the following table. These amounts are updated annually to account for increasing medical care costs.FY 2012 Maximum Nominal Copayment Amounts
| State payment for service | FY 2012 Maximum copayment |
|---|---|
| $10 or less | $0.65 |
| $10.01 to $25 | $1.30 |
| $25.01 to $50 | $2.55 |
| $50.01 or more | $3.80 |
FY 2012 Maximum Nominal Deductible and Managed Care Copayment Amounts
| Deductible | $2.55 |
| Managed Care Copayment | $3.80 |
MAXIMUM ALLOWABLE COPAYMENTS FOR FY 2012
| Services and Supplies | Eligible Populations by Family Income <100% FPL 101-150% FPL >150% FPL |
||
|---|---|---|---|
| Institutional Care (inpatient hospital care, rehab care, etc.) | 50% of cost for 1st day of care | 50% of cost for 1st day of care or 10% of cost | 50% of cost for 1st day of care or 20% of cost |
| Non-Institutional Care (physician visits, physical therapy, etc.) |
$3.80
|
10% of costs | 20% of costs |
| Non-emergency use of the ER | $3.80 | $7.60 | No limit |
| DrugsPreferred drugs Non-preferred drugs |
$3.80 |
$3.80 |
20% of cost |
Medicaid EHR adopting, implementing or upgrading final rule
The Medicaid provisions of the final rule for Adopting, implementing, or upgrading certified EHR technology and Demonstrating meaningful use of EHR technology
Adopting, Implementing, or Upgrading Certified EHR Technology
The final rule:
Demonstrating Meaningful Use of Certified EHR Technology
The final rule:
Adopting, Implementing, or Upgrading Certified EHR Technology
The final rule:
- Discusses that providers in their first year of participation in the Medicaid incentive payment program may demonstrate that they have adopted (e.g. acquired, purchased or secured access to), implemented (e.g. installed or commenced utilization of ) or upgraded to certified EHR technology in order to qualify for an incentive payment;
- Describes the methodology for demonstrating adoption, implementation and upgrading, and for states to monitor these activities;
Demonstrating Meaningful Use of Certified EHR Technology
The final rule:
- Finalizes a shared minimum definition of meaningful use with Medicare. However, CMS will allow states to request CMS approval to require that four public health related measures be core instead of menu measures for Medicaid providers and to specify some of the destination and transmission details;
- Discusses how clinical quality measures reporting will be submitted to the states by Medicaid providers, such as via attestation or electronically via EHRs.
Medicaid EHR PAYMENT - How to get and how much provider get.
Medicaid “Incentive Payments for Eligible Professional
Florida will be ready to begin making the Florida Medicaid EHR incentive payments in September 2011, but you can start preparing now.
The incentive program does not provide additional incentive payments beyond the limits established by legislation, regardless of your EHR system’s cost. The purpose of the incentive payments is to encourage the adoption and meaningful use of certified EHR technology, not to act as a direct reimbursement. The CMS final rule does not dictate how Medicaid providers must use their EHR incentive payment.
Eligible professionals (EPs) can receive $63,750 over six years. Pediatricians who qualify with a 20-29% Medicaid patient volume receive two-thirds of the maximum incentive payment, totaling $42,500. Pediatricians who qualify with a 30% Medicaid patient volume can receive the full incentive payment.
EPs may receive an incentive payment from either Medicaid or Medicare, but not both. A Medicaid eligible professional may receive an incentive payment from only one state in a payment year.
An EP can participate in the Medicaid EHR Incentive Program and CMS eRx Incentive Program simultaneously.
Calendar Year Payment
Year 1 $21,250
Year 2 $8,500
Year 3 $8,500
Year 4 $8,500
Year 5 $8,500
Year 6 $8,500
Total $63,750
Eligible Professionals for Medicaid
Eligible professionals (EPs) are non-hospital-based physicians, dentists, nurse practitioners, and certified nurse midwives. Additionally, physician assistants practicing predominantly in a Federally Qualified Health Center (FQHC)
EPs can receive $63,750 over six years for adopting, implementing or upgrading and demonstrating meaningful use of certified EHR technology. Medicaid providers may opt out of the incentive program without their Medicaid reimbursements being affected. EPs can switch between the Medicare and Medicaid incentive programs one time. The last year for making an incentive program switch is 2014.
Eligible professionals must meet the following patient volume requirements.
Non-Hospital-Based Eligible Professionals Patient Volume Over 90-Day Period
Physician (MD, DO) 30% Medicaid
Dentist 30% Medicaid
Certified Nurse Midwife 30% Medicaid
Nurse Practitioner 30% Medicaid
Physician Assistant (PA) in a RHC or FQHC led by PA* 30% Medicaid
Pediatrician** 20% Medicaid
* Eligible professionals that practice in a RHC or FQHC at least 50% of the time can count “needy individuals”1 to meet their patient volume threshold.
**Pediatricians, like other physicians, can be eligible for the full incentive payment ($63,750) if they meet the minimum 30% Medicaid patient volume requirements. However, Pediatricians only are also eligible if their Medicaid patient volume is between 20-29%. Pediatricians who qualify with a 20-29% Medicaid patient volume receive two-thirds of the maximum incentive payment, totaling $42,500.
*** Non-Hospital-Based is defined as not having 90% or more necounters in a hospital or emergency room setting.
Florida will be ready to begin making the Florida Medicaid EHR incentive payments in September 2011, but you can start preparing now.
The incentive program does not provide additional incentive payments beyond the limits established by legislation, regardless of your EHR system’s cost. The purpose of the incentive payments is to encourage the adoption and meaningful use of certified EHR technology, not to act as a direct reimbursement. The CMS final rule does not dictate how Medicaid providers must use their EHR incentive payment.
Eligible professionals (EPs) can receive $63,750 over six years. Pediatricians who qualify with a 20-29% Medicaid patient volume receive two-thirds of the maximum incentive payment, totaling $42,500. Pediatricians who qualify with a 30% Medicaid patient volume can receive the full incentive payment.
EPs may receive an incentive payment from either Medicaid or Medicare, but not both. A Medicaid eligible professional may receive an incentive payment from only one state in a payment year.
An EP can participate in the Medicaid EHR Incentive Program and CMS eRx Incentive Program simultaneously.
Calendar Year Payment
Year 1 $21,250
Year 2 $8,500
Year 3 $8,500
Year 4 $8,500
Year 5 $8,500
Year 6 $8,500
Total $63,750
Eligible Professionals for Medicaid
Eligible professionals (EPs) are non-hospital-based physicians, dentists, nurse practitioners, and certified nurse midwives. Additionally, physician assistants practicing predominantly in a Federally Qualified Health Center (FQHC)
EPs can receive $63,750 over six years for adopting, implementing or upgrading and demonstrating meaningful use of certified EHR technology. Medicaid providers may opt out of the incentive program without their Medicaid reimbursements being affected. EPs can switch between the Medicare and Medicaid incentive programs one time. The last year for making an incentive program switch is 2014.
Eligible professionals must meet the following patient volume requirements.
Non-Hospital-Based Eligible Professionals Patient Volume Over 90-Day Period
Physician (MD, DO) 30% Medicaid
Dentist 30% Medicaid
Certified Nurse Midwife 30% Medicaid
Nurse Practitioner 30% Medicaid
Physician Assistant (PA) in a RHC or FQHC led by PA* 30% Medicaid
Pediatrician** 20% Medicaid
* Eligible professionals that practice in a RHC or FQHC at least 50% of the time can count “needy individuals”1 to meet their patient volume threshold.
**Pediatricians, like other physicians, can be eligible for the full incentive payment ($63,750) if they meet the minimum 30% Medicaid patient volume requirements. However, Pediatricians only are also eligible if their Medicaid patient volume is between 20-29%. Pediatricians who qualify with a 20-29% Medicaid patient volume receive two-thirds of the maximum incentive payment, totaling $42,500.
*** Non-Hospital-Based is defined as not having 90% or more necounters in a hospital or emergency room setting.
Medicaid and low income people
How can Medicaid help people with low incomes?
Medicaid is a joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. To qualify for Medicaid, you must have a low income and few savings or other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not paid for by Medicare. Medicaid has programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have a low income.
Medicaid is a joint Federal and State program that helps with medical costs for some people with low incomes and limited resources. To qualify for Medicaid, you must have a low income and few savings or other assets. Medicaid coverage differs from state to state. In all states, Medicaid pays for basic home health care and medical equipment. Medicaid may pay for homemaker, personal care, and other services that are not paid for by Medicare. Medicaid has programs that pay some or all of Medicare’s premiums and may also pay Medicare deductibles and coinsurance for certain people who are entitled to Medicare and have a low income.
Medicaid eligibility requirements and covered service
Medicaid
Like Medicare, A Medicaid plan is a Federal health insurance program that provides much needed care for select low-income families. The plan offers health insurance to such people as the disabled, the blind, the aged, and select families with dependent children. Although a Federal program, a Medicaid plan is run by the individual states, allowing for discrepancies amongst whom is eligible, and the extent of the services provided within the resepctive plan. Look below for more information:
Eligibility Requisites:
* Qualify for the Aid to Families with Dependent Children (AFDC) program.
* Children under the age of 6 whose family income is at or below 133% of the Federal Poverty Level. (FPL)
* Pregnant women at or below 133% of the FPL.
* Most States' Supplemental Security Income (SSI) recipients.
* Recipients of adoption or foster care assistance.
* Children under the age of 19 who have incomes below the FPL.
Services Provided by Medicaid plan:
* Inpatient & outpatient hospital services.
* Prenatal care.
* Vaccines for children.
* Physician services.
* 21 and older nursing facility services.
* Family planning services.
* Rural health clinic services.
* Home health care for persons eligible for skilled-nursing services.
* Lab & X-ray services.
* Pediatric and family nurse practitioner services.
* Nurse-midwife services.
* Screening, diagnostic & treatment services for children under 21.
Like Medicare, A Medicaid plan is a Federal health insurance program that provides much needed care for select low-income families. The plan offers health insurance to such people as the disabled, the blind, the aged, and select families with dependent children. Although a Federal program, a Medicaid plan is run by the individual states, allowing for discrepancies amongst whom is eligible, and the extent of the services provided within the resepctive plan. Look below for more information:
Eligibility Requisites:
* Qualify for the Aid to Families with Dependent Children (AFDC) program.
* Children under the age of 6 whose family income is at or below 133% of the Federal Poverty Level. (FPL)
* Pregnant women at or below 133% of the FPL.
* Most States' Supplemental Security Income (SSI) recipients.
* Recipients of adoption or foster care assistance.
* Children under the age of 19 who have incomes below the FPL.
Services Provided by Medicaid plan:
* Inpatient & outpatient hospital services.
* Prenatal care.
* Vaccines for children.
* Physician services.
* 21 and older nursing facility services.
* Family planning services.
* Rural health clinic services.
* Home health care for persons eligible for skilled-nursing services.
* Lab & X-ray services.
* Pediatric and family nurse practitioner services.
* Nurse-midwife services.
* Screening, diagnostic & treatment services for children under 21.
who is eligible for Medicaid and what it is ?
What is Medicaid and who does it cover?
Medicaid is a joint Federal and State program that helps pay medical costs for some people with limited incomes and resources. Most of your health care costs are covered if you have Medicare and Medicaid. Medicaid programs vary from state to state. People with Medicaid may get coverage for services such as nursing home and home health care, that aren’t fully covered by Medicare.
For more information about Medicaid, call your State medical assistance office or visit the Medicaid Section of www.cms.hhs.gov.
You may also be interested in the Medicare Savings Programs. States have programs for people with limited income and resources that pay Medicare premiums and, in some cases, may also pay Medicare deductibles and coinsurance. These programs help millions of people with Medicare save money each year. It's very important to call your State medical assistance office if you think you qualify for the Medicare Savings Programs, even if you aren't sure.
How do I know if I have “full Medicaid coverage?”
If Medicaid covers both your health care and your prescription drugs, you have “full” Medicaid benefits.
Medicaid is a joint Federal and State program that helps pay medical costs for some people with limited incomes and resources. Most of your health care costs are covered if you have Medicare and Medicaid. Medicaid programs vary from state to state. People with Medicaid may get coverage for services such as nursing home and home health care, that aren’t fully covered by Medicare.
For more information about Medicaid, call your State medical assistance office or visit the Medicaid Section of
You may also be interested in the Medicare Savings Programs. States have programs for people with limited income and resources that pay Medicare premiums and, in some cases, may also pay Medicare deductibles and coinsurance. These programs help millions of people with Medicare save money each year. It's very important to call your State medical assistance office if you think you qualify for the Medicare Savings Programs, even if you aren't sure.
How do I know if I have “full Medicaid coverage?”
If Medicaid covers both your health care and your prescription drugs, you have “full” Medicaid benefits.
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