medicare updates 2020...effective 09/14/2020 for many areas including appeals claims congressional...
TRANSCRIPT
1
Medicare Updates 2020
American Association of Healthcare Administrative Management (AAHAM)
Virtual Conference
September 17 2020
Presented By
First Coast Service Options Inc
Provider Outreach amp Education
Ursula Weaver
Provider Relations Representative
1
2
Disclaimer All Current Procedural Terminologyreg (CPTreg) only copyright 2019 American Medical Association (AMA) All rights reserved CPTreg is a registered trademark of the AMA Applicable Federal Acquisition RegulationDefense Federal Acquisition Regulation Supplement restrictions apply to government use Fee schedules relative value units conversion factors andor related components are not assigned by the AMA are not part of CPT and the AMA is not recommending their use The AMA does not directly or indirectly practice medicine or dispense medical services The AMA assumes no liability for data contained or not contained herein
The information enclosed was current at the time it was presented Medicare policy changes frequently links to the source documents have been provided within the document for your reference This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
First Coast Service Options Inc employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide This presentation is a general summary that explains certain aspects of the Medicare program but is not a legal document The official Medicare program provisions are contained in the relevant laws regulations and rulings
No portion or element of this presentation may be copied in whole or in part for profit-making purposes without the express written consent of First Coast Service Options Inc
First Coast Service Options Incs attendance at this event does not constitute or imply endorsement recommendation or favoring of any specific commercial products process or services by trade name trademark manufacturer or otherwise
2
Agenda Items
Coronavirus (COVID-19)
Medicare updates
One Medicare Learning Networkreg (MLNreg) Mattersreg (MM) articles one special edition (SE) articles
Prior authorization (PA) for certain outpatient department (OPD) services
Qualified Independent Contractor (QIC) Part A appeals East (PAE) demonstration
Online resources
3
3
Learning Objectives
At the conclusion of todays session youll be able to
bull Locate updates about COVID-19 bull Define Medicare changes and updates
that can have an impact on your facility bull Review requirements of PA for certain
OPD services bull Discuss and participate in the QIC
appeals demonstration bull Review online resources to be
proactive in your day-to-day operations
4
COVID-19 Updates
5
4
COVID-19
6
COVID-19 Resources
Update concerning the public health emergency (PHE) in response to the 2019 novel COVID-19 pandemic
COVID-19 Partner Toolkit
SE20011 Medicare Fee-for-Service (FFS) Response to the PHE on COVID-19
COVID-19 Frequently-asked Questions (FAQs) on Medicare FFS billing
Telehealth resources
Article COVID-19 Correctly billing telehealth and telephone-only service during the emergency
Medicare Learning Networkreg (MLNreg) video Medicare coverage and payment of virtual services
7
5
Claims Processing Issues
COVID Dear Clinician letter Diagnosis codes Z03818 Z20828 and Z1159
Allowing claims with Z diagnosis
codes Diagnosis codes Z03818 and Z1159 denied in error for claims
processed prior to July 17 2020
COVID-19 Correcting telehealth
services billed with place of service
(POS) 02 8
COVID-19 Testing Update
COVID-19 Allowances for laboratory
test codes U0001-U0004 0202U
0223U 0224U 0225U 0226U
86408 86409 87426 and 87635
9
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
2
Disclaimer All Current Procedural Terminologyreg (CPTreg) only copyright 2019 American Medical Association (AMA) All rights reserved CPTreg is a registered trademark of the AMA Applicable Federal Acquisition RegulationDefense Federal Acquisition Regulation Supplement restrictions apply to government use Fee schedules relative value units conversion factors andor related components are not assigned by the AMA are not part of CPT and the AMA is not recommending their use The AMA does not directly or indirectly practice medicine or dispense medical services The AMA assumes no liability for data contained or not contained herein
The information enclosed was current at the time it was presented Medicare policy changes frequently links to the source documents have been provided within the document for your reference This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations Although every reasonable effort has been made to assure the accuracy of the information within these pages the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services
First Coast Service Options Inc employees agents and staff make no representation warranty or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide This presentation is a general summary that explains certain aspects of the Medicare program but is not a legal document The official Medicare program provisions are contained in the relevant laws regulations and rulings
No portion or element of this presentation may be copied in whole or in part for profit-making purposes without the express written consent of First Coast Service Options Inc
First Coast Service Options Incs attendance at this event does not constitute or imply endorsement recommendation or favoring of any specific commercial products process or services by trade name trademark manufacturer or otherwise
2
Agenda Items
Coronavirus (COVID-19)
Medicare updates
One Medicare Learning Networkreg (MLNreg) Mattersreg (MM) articles one special edition (SE) articles
Prior authorization (PA) for certain outpatient department (OPD) services
Qualified Independent Contractor (QIC) Part A appeals East (PAE) demonstration
Online resources
3
3
Learning Objectives
At the conclusion of todays session youll be able to
bull Locate updates about COVID-19 bull Define Medicare changes and updates
that can have an impact on your facility bull Review requirements of PA for certain
OPD services bull Discuss and participate in the QIC
appeals demonstration bull Review online resources to be
proactive in your day-to-day operations
4
COVID-19 Updates
5
4
COVID-19
6
COVID-19 Resources
Update concerning the public health emergency (PHE) in response to the 2019 novel COVID-19 pandemic
COVID-19 Partner Toolkit
SE20011 Medicare Fee-for-Service (FFS) Response to the PHE on COVID-19
COVID-19 Frequently-asked Questions (FAQs) on Medicare FFS billing
Telehealth resources
Article COVID-19 Correctly billing telehealth and telephone-only service during the emergency
Medicare Learning Networkreg (MLNreg) video Medicare coverage and payment of virtual services
7
5
Claims Processing Issues
COVID Dear Clinician letter Diagnosis codes Z03818 Z20828 and Z1159
Allowing claims with Z diagnosis
codes Diagnosis codes Z03818 and Z1159 denied in error for claims
processed prior to July 17 2020
COVID-19 Correcting telehealth
services billed with place of service
(POS) 02 8
COVID-19 Testing Update
COVID-19 Allowances for laboratory
test codes U0001-U0004 0202U
0223U 0224U 0225U 0226U
86408 86409 87426 and 87635
9
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
3
Learning Objectives
At the conclusion of todays session youll be able to
bull Locate updates about COVID-19 bull Define Medicare changes and updates
that can have an impact on your facility bull Review requirements of PA for certain
OPD services bull Discuss and participate in the QIC
appeals demonstration bull Review online resources to be
proactive in your day-to-day operations
4
COVID-19 Updates
5
4
COVID-19
6
COVID-19 Resources
Update concerning the public health emergency (PHE) in response to the 2019 novel COVID-19 pandemic
COVID-19 Partner Toolkit
SE20011 Medicare Fee-for-Service (FFS) Response to the PHE on COVID-19
COVID-19 Frequently-asked Questions (FAQs) on Medicare FFS billing
Telehealth resources
Article COVID-19 Correctly billing telehealth and telephone-only service during the emergency
Medicare Learning Networkreg (MLNreg) video Medicare coverage and payment of virtual services
7
5
Claims Processing Issues
COVID Dear Clinician letter Diagnosis codes Z03818 Z20828 and Z1159
Allowing claims with Z diagnosis
codes Diagnosis codes Z03818 and Z1159 denied in error for claims
processed prior to July 17 2020
COVID-19 Correcting telehealth
services billed with place of service
(POS) 02 8
COVID-19 Testing Update
COVID-19 Allowances for laboratory
test codes U0001-U0004 0202U
0223U 0224U 0225U 0226U
86408 86409 87426 and 87635
9
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
4
COVID-19
6
COVID-19 Resources
Update concerning the public health emergency (PHE) in response to the 2019 novel COVID-19 pandemic
COVID-19 Partner Toolkit
SE20011 Medicare Fee-for-Service (FFS) Response to the PHE on COVID-19
COVID-19 Frequently-asked Questions (FAQs) on Medicare FFS billing
Telehealth resources
Article COVID-19 Correctly billing telehealth and telephone-only service during the emergency
Medicare Learning Networkreg (MLNreg) video Medicare coverage and payment of virtual services
7
5
Claims Processing Issues
COVID Dear Clinician letter Diagnosis codes Z03818 Z20828 and Z1159
Allowing claims with Z diagnosis
codes Diagnosis codes Z03818 and Z1159 denied in error for claims
processed prior to July 17 2020
COVID-19 Correcting telehealth
services billed with place of service
(POS) 02 8
COVID-19 Testing Update
COVID-19 Allowances for laboratory
test codes U0001-U0004 0202U
0223U 0224U 0225U 0226U
86408 86409 87426 and 87635
9
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
5
Claims Processing Issues
COVID Dear Clinician letter Diagnosis codes Z03818 Z20828 and Z1159
Allowing claims with Z diagnosis
codes Diagnosis codes Z03818 and Z1159 denied in error for claims
processed prior to July 17 2020
COVID-19 Correcting telehealth
services billed with place of service
(POS) 02 8
COVID-19 Testing Update
COVID-19 Allowances for laboratory
test codes U0001-U0004 0202U
0223U 0224U 0225U 0226U
86408 86409 87426 and 87635
9
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
6
COVID-19 Part A Updates
Cost reporting updates
Suspension of 2 sequestration for biweekly periodic interim payment (PIP) and pass-through payments
Suspended through 12312020
Medicare Graduate Medical Education (GME) Affiliation Agreement
Teaching hospitals have until 10012020 to submit new or amended Medicare GME affiliated group agreements
Page eight of 41
10
Medicare Updates
11
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
7
New mailing addresses for First Coast correspondence
12
Contact Center
Effective 09142020
For many areas including
Appeals
Claims
Congressional inquiries
Customer service
Debt recovery
Medical review
Provider audit and reimbursement
Provider Outreach and Education
Redeterminations
Forms updated with new addresses
Use current forms 13
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
8
MM11882
Influenza Vaccine Payment Allowances -- Annual Update for 2020-2021 Season
Effective 08012020 Implementation 10012020
Approved payment allowances for influenza vaccines are posted to Centers for Medicare amp Medicaid Services (CMS) Seasonal Influenza Vaccines Pricing website
Effective 08012020-07312021
Medicare Administrative Contractors (MACs) will determine allowance for Healthcare Common Procedure Coding System (HCPCS) Q2039
First Coast will reprocess any flu vaccine claims priced with allowances other than these by 11012020
Full code descriptors and payment allowances found on website
Coinsurance and deductible do not apply 14
Post-payment Reviews Resumed
Effective 08172020
Specific ItemsServices
Service-specific reviews currently in
effect
15
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
9
CERT Reviews Resumed
Effective 08112020 Resumed
Mailing documentation request letters
Conducting phone calls
Mailed subsequent additional documentation requests (ADRs) that were active on March 27
Mailed subsequent ADRs identified but not yet sent during the temporary suspension
16
PA for Certain OPD Services Overview
17
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
10
OPD Program Overview
Nationwide program - implementation effective June 17 2020 for dates of service (DOS) on or after July 1 2020
Program will include hospital OPDs that provide certain OPD services and are enrolled in Medicare FFS program
For services reported on a type of bill (TOB) 13x
PA program does not change Medicare benefit or coverage requirements nor does it create new documentation requirements
CMS Prior Authorization for Certain Hospital OPD Services
18
OPD Services
As a condition of payment for DOS on or after July 1 2020 a prior authorization request (PAR) is required for the following hospital OPD services
Blepharoplasty Eyelid Surgery Brow Lift and Related Services
Botulinum toxin injections
Panniculectomy - Excision of Excess Skin and Subcutaneous Tissue (Including Lipectomy) and Related Services
Rhinoplasty and Related Services
Vein ablation and Related Services
CMS provides a list of the HCPCS codes included in the OPD PA program
19
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
11
PAR
20
PAR Submission Requirements
Hospital OPD provider must submit a PAR before
bull Providing services to Medicare beneficiaries
bull Submitting claims for payment
bull Note Physiciansproviders may complete the request on behalf of the hospital OPD
PAR must include
bull All documentation necessary to demonstrate the service meets applicable Medicare coverage coding and payment rules
bull Certain data elements to avoid potential delays in processing of the initial submission documents
bull First Coast will deny claims that require PA if provider has not received affirmation of coverage
21
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
12
PAR-related Terms
MBI = patientrsquos Medicare Beneficiary Identifier
NPI = National Provider Identifier
UTN = Unique Tracking Number ndash assigned to each PAR
CMS certification number also referred to as the PTAN (Provider Transaction Access Number) or plainly provider number
22
Potential PAR Responses
Prov isional affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are met
Prov isional partial affirmation
bull Issued to the provider when one or more service(s) on the PAR received provisional affirmation decision and one or more service(s) received a non-affirmation decision
Non-affirmation
bull Issued to the provider if applicable Medicare coverage coding and payment rules are not met
bull Detailed information about missing requirements and non-compliant information will be provided via fax mail or the Secure Provider Online Tool (SPOT)
23
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
13
Subsequent submission of PAR to correct an error or omission identified during a PA decision
Resubmission should include initial PAR information
Exact match of beneficiaryrsquos first name last name date of birth to the previous submission
UTN associated with previous submission
Provider may resubmit PAR with additional supporting information upon receipt of non-affirmation as many times as necessary to achieve an affirmation decision
UTN will be assigned to each resubmission request
24
Resubmission
Submitting PAR
bull First Coast Service Options Inc bull JN Prior Authorization bull 2020 Technology Parkway
bull PO Box 3033 bull Mechanicsburg PA 17055-1804
Fax bull 1-855-815-3065
esMD bull content type 85
Portal bull SPOT
25
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
14
Priority mail
First Coast Service Options Inc
Attention JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg PA 17050
Phone 1-855-340-5975 (Prior Auth Customer Service)
26
Additional PAR Options
PA submitted (or re-submitted) to First Coast
Within 10 business days medical determination is made
For provisional affirmation
Date 1 of 120 begins on the day the decision is made
UTN and date range of authorization are specified on approval notice
Service MUST be performed within 120 days
If DOS outside of 120 days = prior authorization does not apply (UTN no longer valid - a new PAR will be needed)
Existing claim timely filing guidelines apply (within one year)
27
PA Timeframes
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
15
Providers may submit claims for PARs that have received provisional affirmation
TOB 13X
UTN from the decision letter must be reported
If all Medicare coverage coding and payment requirements are met claim will likely be paid
First Coast will deny claims submitted when PAR has received a non-affirmed PA decision
Claims submitted to First Coast without PA decision on file will automatically deny
Associated or related services also denied including but not limited to
Physician and facility services
Anesthesiology 28
Claims
Reporting the UTN
Electronic claims
Submit UTN in the 2300 - Service Line loop in the Prior Authorization reference (REF) segment
REF01 = G1 qualifier and REF02 = UTN
Meets requirements of ASC X12 837 Technical Report 3 (TR3)
Direct data entry (DDE)
Enter UTN in Treatment Authorization field on DDE Page 05 (MAP1715)
Uniform bill (UB)-04
Submit UTN in Form Locator 63
Report UTN on the same line (A B C) that Medicare is shown in Form Locator 50 (Payer Line A B C)
UTN should begin in position 1 of Form Locator 63 29
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
16
Following claim types are excluded
from the PA program unless
otherwise specified Veterans Affairs
Indian Health Services
Medicare Advantage
Part A and Part B Demonstration
Medicare Advantage sub-category indirect medical education (IME) only claims
Part AB rebilling
30
Claim Exclusions
Timeframes have not accounted for
COVID testing PA received within 10 days ndash COVID testing may cause further
delay
Valid for 120 days ndash COVID testing must be completed
31
Consider COVID
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
17
Points to Remember
Authorization needed for services in
OPD = hospital needs authorization Claims related to or associated with services that require PA as
condition of payment will not be paid if the service requiring PA is not also paid (ie anesthesiology physician or facility services)
PA applies to certain OPD services
billed on TOB 13X PA does not apply to ambulatory surgical centers (ASCs) or office
visit services
Applies to POS 22
32
Points to Remember (Cont)
PAR has required elements ndash if not
completed in full will be dismissed Ensure PAR being sent to correct MAC
Addresses are needed
UTN only has number lsquo0rsquo ndash not letter
lsquoOrsquo (ie 0HA0000000XXXX)
33
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
18
Prior Authorizations Page
Prior authorization coversheet instructions
Access the OPD prior authorization coversheet
View general documentation requirements
For all five categories of service ndash with codes included
Hospital outpatient department (HOPD) services PA calculator
Learning On Demand
34
CMS Resources
Prior Authorization for Certain HOPD
Services OPD Frequently Asked Questions
OPD Operational Guide
Final list of outpatient services that
require prior authorization
35
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
19
QIC Part A Appeals Demonstration
36
Appeals Demonstration
Background January 1 2016 CMS implemented telephone discussion and
reopening process demonstration for Durable Medical Equipment (DME)
Originally limited to oxygen and glucose diabetic testing supplies in two jurisdictions
Now includes all four DME MAC Jurisdictions and most claim types
April 1 2019 Demonstration expanded to include appeals in the PAE QIC jurisdiction
Demonstration currently extended to December 31 2021
Participation in the appeals demonstration is voluntary
37
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
20
Two Parts of Demonstration
PAE Appeals Demonstration
Telephone Discussions
Discussions with decision maker on incoming
reconsiderations before decision is rendered
Reopening Process
Appeals pending at ALJ on which C2C is
conducting analysis to potentially resolve
favorably
38
Benefits of Participation
Telephone discussion Engage in discussion of appealed claims prior to issuance of
reconsideration decision
C2C health care professionals have opportunity to educate providers on complex medical necessity documentation requirements for specific services
Provider has until 14 days after discussion to submit any missing or critical documentation needed to secure payment
Goal of discussion is for providers to have enhanced understanding of Medicare requirements for their medically necessary services and improve future claim submissions
39
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
21
Telephone Discussion Process
Prior to telephone discussion C2C conducts cursory review of case
Mails out scheduling letter
Date and time of scheduled call
If missing documentation is identified C2C will notify you in scheduling letter
Choosing to participate Contact form needs to be returned to C2C within 14 days
Name of person who will participate in telephone discussion
Telephone number for them to be contacted
40
Telephone Discussion Process2
Participation
Allows QIC 120 days to process reconsideration rather than existing 60 days
You do not lose your appeal rights
If appeal denied after telephone discussion you still have ability to appeal to next level
Providers who use third party to
handle appeals Reach out to Ademofeedbackc2cinccom
41
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
22
Reopening Process
Provider actions Providers notified in writing if appeal is identified as potential
reopening along with missing or insufficient documentation required to allow payment
Providers have 30 days from date of the letter to return requested documentation
If requested documentation is not received C2C will not proceed with the reopening
Providers may submit a request for a potential reopening on the reconsideration request form
42
Reopening Process2
Upon receipt of requested documentation C2C will confirm if documents support a favorable decision
If documentation supports favorable decision upon receipt of the remand from Office of Medicare Hearings and Appeals (OMHA) C2C will reopen and render favorable decision
If favorable decision cannot be rendered provider will be notified in writing and appeal will remain at OMHA
Appeal does not lose placement at the Administrative Law Judge (ALJ)
43
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
23
How Can I Participate
Telephone discussion You may indicate your interest in participating in a discussion on
your reconsideration request that is mailed to C2C
For more information visit
wwwc2cinccom
For general comments or questions
Ademofeedbackc2cinccom
C2C Innovative Solutions Inc--Part A East Appeals Demonstration
904-224-7371 (phone)
904-224-2732 (fax)
44
Tips to Help Improve
Claim Decisions
45
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
24
First Coast Tips
Familiarize yourself with Information about services you provide
Contained in local coverage determinations (LCDs) and national coverage determinations (NCDs)
Do you know the indications and limitations of coverage
Have you met coding guidelines
Did you follow the documentation requirements
Utilize self-service tools Documentation checklists
Specialty pages
Medical policy articles
46
QIC Tips
How to prepare for a telephone
discussion Make sure address on reconsideration request is address you
want correspondence mailed to
Make sure you are available at time of scheduled call
Have documents pertaining to case available to you during the call
Have questions concerns and verbal testimony prepared
Be prepared to provide additional medical documentation if documentation already provided is missing or insufficient to meet coverage criteria
47
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
25
Online Resources
48
First Coast Provider Website
English or Spanish
49
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
26
First Coast Resources
Join eNews
Events calendar
Billing news
Institutional provider web page
50
New Online Learning Modules
Announcing eight
new online
learning modules
First Coast University course catalog (B)
First Coast University course catalog (A)
51
Title CEUs
Chiropractic serv ices (B)
1
Drugs amp Biologicals (A)
1
Drugs amp Biologicals (B)
1
Incident-to serv ices (B)
1
Medicare cov erage policies (AB)
1
NCCI program ov erv iew (AB)
1
SNF consolidated billing (A)
1
Spiltshared serv ices (B)
1
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
27
Provider Enrollment Education
Informational videos
Short three-to-five-minute videos on top inquiries and application development reasons
How do I complete and submit the CMS-588 electronic funds transfer (EFT) form
Understanding billing gaps
Avoid mismatched names when completing Medicare enrollment forms
Difference between sole owner and sole proprietor
More videos coming soon
Provider Enrollment Chain and Ownership System (PECOS) Identity amp Access (IampA) Management System Final adverse legal actions Revised CMS-855R and Revalidation
52
SPOT
SPOT updates SPOT applications average processing time is about 5 days
MBI lookup retrieve an MBI for a beneficiary up to four years from the beneficiarys date of death
Request for pre-approval for certain outpatient procedures available as of June 17
Second level of appeals requestreconsideration currently in development 2021
53
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
28
CMS
54
CMS Resources
Transmittals
Internet-only manual (IOM)
55
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
29
Summary of Todays Topics
Today we Located updates about COVID-19
Defined Medicare changes and updates that can have an impact on your facility
Reviewed requirements of PA for certain OPD services
Discussed and learned how to participate in the QIC appeals demonstration
Reviewed online resources to be proactive in your day-to-day operations
56
Question and Answer Session
What questions do you have
57
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
30
Thank You for Participating
First Coast values your feedback Please complete your evaluation form and return via email
58
Acronym List
AAHAM American Association of Healthcare Administrative Management
ADR Additional documentation request
ALJ Administrative Law Judge
AMA American Medical Association
ASC Ambulatory surgical center
CMS Center for Medicare amp Medicaid Services
COVID Coronavirus
CPT Current Procedural Terminology
DDE Direct data entry
DME Durable medical equipment
DOS Date of service
59
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
31
Acronym List 2
EFT Electronic funds transfer
esMD Electronic submission of medical documentation
FAQ Frequently asked question
FFS Fee-for-service
GME Graduate Medical Education
HCPCS Healthcare Common Procedure Coding System
HOPD Hospital outpatient department
IampA Identity amp Access
IME Indirect Medical Education
IOM Internet-only manual
LCD Local coverage determination
MAC Medicare Administrative Contractor
60
Acronym List 3
MBI Medicare beneficiary identifier
MLNreg Medicare Learning Networkreg
NCD National coverage determination
NPI National Provider Identifier
OMHA Office of Hearings and Appeals
OPD Outpatient department
POS Place of service
PA Prior authorization
PAE Part A East
PAR Prior Authorization Request
PECOS Provider Enrollment Chain and Ownership System
PHE Public Health Emergency
PIP Periodic interim payment 61
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
32
Acronym List 4
PTAN Provider Transaction Access Number
QIC Qualified Independent Contractor
SPOT Secure Provider Online Tool
TOB Type of bill
UB Uniform bill
UTN Unique tracking number
SPOT Secure Provider Online Tool
62
What is the Florida Sunshine Chapter AAHAM
Florida Sunshine Chapter AAHAM is a networking group of Healthcare Rev enue Cy cle
Management prof essionals throughout Florida Florida Sunshine Chapterrsquos mission is to
provide education certification networking career guidance and opportunities and
advocacy for all healthcare revenue cycle professionals
AAHAM is dedicated to giv ing y ou the inside intelligence y ou need to thriv e prof essionally As
a member y ou hav e access to inf ormation on critical topics like education and adv ocacy in the
areas of reimbursement admitting and registration data management medical records
patient relations and so much more
For more information on benefits and to join online v isit wwwf loridaaahamcom
Interested in joining FL AAHAM Email us at membershipf loridaaahamcom
Follow us on LinkedIn httpswwwlinkedincomcompany florida-sunshine-chapter-aaham
Join us on Facebook httpswwwf acebookcomf loridasunshineaaham
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable
33
AAHAM Florida Sunshine Chapter 2020 Corporate Partners
Platinum
OSGDiamond Healthcare Solutions
Gold Partners
Change Healthcare
Gulf Coast Collection Bureau Inc
Silver Partners
C3 Revenue Cycle Solutions
Penn Credit Corporation
SNS Recovery Inc
Bronze Partners
Bacen amp Jordan PA
DECO LLC
EnableComp
Firm Revenue Cycle
Health Pay 24
MSCB Inc
MyCare Finance
NobleBiz
OVAG International
Sage Law Offices
W e w ould like to thank all of our Corporate Sponsors for making a financial commitment to our Chapter and w e ask that all members make a special effort to
thank them for their continued support and include them in evaluation of needs andor RFP process w hen applicable