CA AAHAM Conference Provider Outreach & Education

December 2013

DISCLAIMER

This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents.

The information is provided “as is” without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice.

All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov

The identification of an organization or product in this information does not imply any form of endorsement.

CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved. Applicable FARS/DFARS apply.

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Agenda

• Noridian & CMS Updates • 2 Mid-Night Provision • A/B Rebilling • Dual Eligibility-Crossover Claims • CERT

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Noridian & CMS Updates

Did You Hear?

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Subscribe to Email list for updates from CMS and Noridian, including announcement of events for providers

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• Noridian would love your website feedback! – Complete Foresee Results Survey

• Provide constructive and complimentary feedback – Help continue growth in webinar customer service

Website Survey

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Noridian Workshops – Part A

December 2013 7

Noridian Workshops – Part B

December 2013 8

Check the Noridian Website

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PECOS Ordering/Referring Providers

• CMS instructed contractors to implement Phase II denial edits January 6, 2014

• Refer to Special Edition (SE)1305 – http://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1305.pdf

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Update on Incarceration Claim Denials

• Issue corrected • Payments made • Letters to be sent out by end of December • Contact the PCC at 1-855-609-9960 if you do

not receive the letter • For more information see:

• https://med.noridianmedicare.com/web/jea/topics/claim-submission/incarceration-claim-denials

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New Patient E/M Resolution

• CR8165 - Common Working File (CWF) Informational Unsolicited Reports (IUR) or Reject for A New Patient Visit Billed by the Same Physician or Physician Group within the Past Three Years – Part B claims hitting CWF Error Codes 33x4,

33x5, 7579 and 7580

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New Patient E/M Resolution2

• Noridian Provider Alert Update: – 12/04/13: Providers should see the mass

adjusted corrected claims on their remits within the next 5 to 7 business days. If a provider believes a clerical correction is needed to change the new patient evaluation and management (E&M) services to an established E&M, please follow these guidelines:

• If the initial paid date of the claim is less than one year ago, providers may do a Phone Reopening or a Written Reopening

• If the initial paid date of the claim is over one year, providers may only do a Written Reopening

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Non-Medical ADR Requests

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• SB6001 – Edit 32105 • Avoid claim rejections by setting up either: • 1:1 NPI to PTAN match or • Set up the 5 or 9 digit Zip Codes with each PTAN for

your Facility

Correct Provider Billing of Admission Date and Statement Covers Period

• Effective for inpatient hospital claims submitted on or after October 1, 2011 and claims with a discharge date of July 1, 2011 forward: – Admission Date (UB04 Form Locator 12) = date the patient was

admitted as an inpatient to the facility. – Statement Covers Period (UB04 Form Locator 6) = span of

service dates; "From" date is the earliest date of service on the bill.

• On the inpatient claim a valid "from" date could be up to and including 3-days (or 1 day) prior to the actual inpatient admission based on the pre-admission bundling rule.

• Sources: IOM Medicare Claims Processing Manual,

Publication 100-04, Chapter 3, Section 40.3; CMS MLN Article SE1117.

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CR/MM 8248

• Termination of the Common Working File ELGA, ELGH, HIQA, HIQH, and HUQA Part A Provider Queries – Effective 4/7/14 – Providers will need to use HIPAA Eligibility

Transaction System (HETS)

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CR/MM 8465

• ICD-10 Testing with Providers through the Common Edits and Enhancements Module (CEM) and Common Electronic Data Interchange (CEDI) – Effective March 2014 – Announces plans for front-end ICD-10 testing

between MACs and their trading partners – The testing week will be March 3 through

March 7, 2014 December 2013 17

2 Mid-Night Provision

2 Mid-Night Provision

• CMS Rule 1599-F: Inpatient Hospital Admission and Medical Review Criteria (2-Midnight Provision) and Part B Inpatient Billing in Hospitals – Final Rule:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-Final-Rule-Home-Page.html

– Provider Information & FAQs: http://go.cms.gov/InpatientHospitalReview

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2 Mid-Night Provision2

• CMS Education – CMS ODF calls held – FAQs available on the CMS website – Hospital Inpatient Admission Order and

Certification – Reviewing Hospital Claims for Patient Status:

Admissions On or After October 1, 2013 • Feedback & Questions to CMS at:

mailto:IPPSAdmissions@cms.hhs.gov

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2 Mid-Night Provision3

• Noridian – Probe & Education Probram – Probe reviews of 10 – 25 claims to be done

• Edit 504IP • Types of facilities included in review

– Acute care Inpatient Prospective Payment System (IPPS) facilities

– Long Term Care Hospitals (LTCHs) – Inpatient Psychiatric Facilities (IPFs)

• Dates of Admission under review: October 1, 2013 through March 31, 2014

• Length of stay: 0-1 midnights

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2 Mid-Night Provision4

• Noridian – Probe reviews

• Records due within 30 days • Reviews to be done within 30 days of receipt • Results of the review will be provided • Denials may result in future complex reviews

– See article posted to web 12/5/13 • https://med.noridianmedicare.com/web/jea/article-

detail/-/view/10521/notification-of-initiation-of-probe-reviews-in-relation-to-final-rule-cms-1599-f

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2 Mid-Night Provision5

• Resources – Inpatient Hospital Reviews: http://www.cms.gov/Research-Statistics-

Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

– Selecting Hospital Claims for Patient Statues Reviews: Admissions On or After October 1, 2013: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/SelectingHospitalClaimsforAdmissionsonorafterOctober1st2013forReviewForWebPostingCLEAN.pdf

– Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionFINAL.pdf

– Final Rule CMS-1599-F: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

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A/B Rebillings

Reference: SE1333

A/B Rebilling

• CMS Instructions – For Self Audit Claims - Provider Liable – Inpatient claim must be submitted as follows:

• Type of Bill (TOB) 110 in Form Locator (FL) 4 • Non-covered Days • The services from admission through discharge • The appropriate patient status • Occurrence Span Code “M1” and dates of service • Non-covered charges for all services rendered

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A/B Rebilling2

– Self audit claim requirements - Continued • All diagnosis codes • All procedure codes

– After the inpatient claim processes and remittance advice issued

• Submit inpatient Part B claims; TOB 12X

• For Part A Inpatient admissions denied as not reasonable and necessary

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A/B Rebilling3

• For Part A Inpatient admissions denied as not reasonable and necessary – Submit inpatient Part B claims; TOB 12X

• A treatment authorization code of A/B Rebilling submitted by a provider.

• NOTE: Providers billing an 837I shall place the appropriate Prior Authorization code above into Loop 2300 REF02 (REF01 = G1) as follows:

– REF*G1*A/B Rebilling • Condition code "W2" attesting that this is a rebilling and no

appeal is in process; and • The original, denied inpatient claim (CCN/DCN/ICN) number • NOTE: Providers billing an 837I shall place DCN in the Billing

Notes loop 2300/NTE in the format: – NTE*ADD*ABREBILL12345678901234

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A/B Rebilling4

• For DDE or paper Claims – Enter "ABREBILL" plus the denied inpatient

DCN/CCN/ICN in the Remarks Field (form locator #80) on the claim using the following format: "ABREBILL12345678901234".

• Claim Editing Issues – RC 39011: Resolved – RC 31796: Reviewed & determined to be

correct editing – RC 39015: Researching

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Dual Eligibility Crossover Claims

Dual Eligibility

• Crossover claims – Medicare contractors coordinate with the

Coordination of Benefits Contractor (COBC) – Automatically crossover claims payment

information for their policyholders – Eligibility file furnished by the supplemental

insurer is used to drive the process rather than information found on the claim

– Eligibility files are matched, based on the Health Insurance Claim (HIC) number, against Medicare’s internal eligibility file

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Dual Eligibility2

• Crossover Claims – Continued – If a match occurs, the beneficiary’s record is

flagged indicating to which company we will cross claim payment information.

– Noridian than sends the file of claims to the COBC who consolidates the claims for all contractors and forwards it on to the trading partner/supplemental insurer.

– If no match occurs, the claim is not flagged for crossover.

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Dual Eligibility3

• Crossover Claims – Continued – Each trading partner/supplemental insurer is

given the opportunity to specify criteria related to the claims the insurer wants or does not want Medicare to crossover.

– Trading partner/supplemental insurer can choose from list of conditions to allow or refuse a claim crossover from Medicare.

• Automated process – Normally no issues

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Dual Eligibility4

• Reference COBC-Crossover Claims – Part A

https://med.noridianmedicare.com/web/jea/topics/msp/cobc

– Part B https://med.noridianmedicare.com/web/jeb/topics/msp/cobc

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Comprehensive Error Rate Testing (CERT)

CERT

• Issues and Updates – Itemized Statements Omitted When

Requested by CERT • Results in increased errors • Providers are reminded to ensure all necessary

records are submitted to support the services rendered

• Missing itemized statement will result in a CERT error finding whether or not there is any effect on reimbursement

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CERT2

• Issues and Updates – CERT Documentation Submission Timeliness

Update • Effective for reviews on or after 1/1/14 • Change the response time for CERT requests for

Initial Documentation to 60 days, down from 75 days

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CERT3

– CERT Documentation Submission Timeliness Update – Continued

• Follow-up call and letter time frame from CERT will change as well

– Day 0: Contact and/or send letter 1 via fax or mail – Day 30: Contact and/or send letter 2 via fax or mail – Day 45: Contact and/or send letter 3 via fax or mail – Day 60: If no records were received, full claim denial

• Response time for Additional Documentation requests remains 15 days

• Noridian follow-up calls – Day 35 for Initial Documentation requests – Day 7 for Additional Documentation requests

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Questions?

Thank you.