wyoming medicaid covered services & billing …...(speak to agent) questions concerning claims,...
TRANSCRIPT
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Immunization Conference
Wyoming Medicaid
Covered Services & Billing Requirements
May 11 & 12, 2016
Presenter’s: Melissa Davis & Elisa Mauch, Field Representative’s
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What is Medicaid?
• Medicaid helps pay for healthcare services for children, pregnant women, families with children, and individuals who are aged/blind/disabled who qualify based on citizenship, residency, family income, and sometimes resources and healthcare needs.
• Non- citizens may be eligible for emergency services.
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CMS 1500 Provider Manual
Located on the Medicaid website http://wymedicaid.acs-inc.com
Select Provider
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CMS 1500 Provider Manual
• Select Provider Manuals and Bulletins(Navigation Bar on Left)
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CMS 1500 Provider Manual
• Select Nurse Practitioner within the CMS 1500 Provider Manual and Bulletins section
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CMS 1500 Provider Manual
• Select CMS 1500 Provider Manual
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CMS 1500 Provider Manual
• Review for New/Updated Information
• Important Policy Changes/Additions section
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CMS 1500 Provider Manual
• CMS 1500 Provider Bulletins Section
• Additional Links section - Medicaid and State Healthcare Benefit Plans
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CMS 1500 Provider Manual
Covered Services Chapter 21 – Covered Services - Practitioner
Services Section 21.1 – Physician and Nurse Practitioner Services
Covered services and billing requirements specific to physicians and practitioners
21.7.1 – Immunizations
WyVIP
Private stock
Administration
Billing examples
21.17 – Public Health Services
Definition
Non-Covered Services
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21.7.1 Immunizations
Billing Procedures (21.7.1) WyVIP supplied vaccines
Private Stock - Privately purchased vaccines
WyVIP Supplied Provided free of charge to eligible Medicaid clients 18 years and younger
Vaccine reimbursement: $0 reimbursement for vaccine (i.e. TDAP, MMR, influenza, etc.)
Bill with vaccine procedure code (90477-90748) and SL modifier (indicates WyVIP)
Administration reimbursement: reimburses from fee schedule
Bill appropriate vaccine administration code
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21.7.1 Immunizations
Private Stock / Privately Purchased Vaccines (21.7.1)
WyVIP was out of stock
The vaccine was not supplied through the WyVIP Program
Vaccine reimbursement: reimburses at cost (invoice) or from fee schedule, dependent on procedure code and client’s age
Bill appropriate vaccine procedure code
Do not bill with the SL modifier
Administration reimbursement: reimburses from fee schedule regardless of how the vaccine was acquired
Bill appropriate vaccine administration code
Bill usual and customary charges
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21.7.1 Immunizations
Private Stock / Privately Purchased Vaccines (continued)
Private Stock Payment Methodology
Clients 19 yrs and older / Fee Schedule
No invoices required
Vaccine procedure codes
Influenza (90656 - $15.00, 90658 - $20.00 , 90660 - $15.00)
Tetanus (90703 - $15.00)
MMR (90707 - $15.00)
TD (90714 - $15.00)
TDAP (90715 - $30.00)
Clients 18 yrs and under / Invoice
Invoices required (Medicaid Fee Schedule)
Vaccine procedure codes same as above
Invoices required / Invoice
All other vaccine codes for any age
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Medicaid Fee Schedule
http://wymedicaid.acs-inc.com (Wyoming Medicaid Website)
Select Provider
Select Fee Schedules
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Medicaid Fee Schedule
• Accept the agreement
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Medicaid Fee Schedule
• Select Try our Procedure Code Search page
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Medicaid Fee Schedule
• Enter Procedure Code
• Select Search
• Review the Procedure Code Legend for important and helpful information
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Vaccination Administration Codes
(18 or younger, with counseling)
Administration Codes – Ages 0 – 18 with Face-to-Face Vaccine Counseling
CPT
Code Description
90460
Immunization administration through 18 years of age via any route of administration, with
counseling by physician or other qualified health care professional; first or only component of
each vaccine or toxoid administered
90461
Immunization administration through 18 years of age via any route of administration, with
counseling by physician or other qualified health care professional; each additional vaccine or
toxoid component administered (list separately in addition to code for primary procedure)
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For each vaccination given, the first or only component (antigen) is billed using 90460, each additional
component/antigen is billed using 90461. Like codes must be combined onto one line with multiple units.
90461 is reimbursed at $0, and is used for tracking purposes only.
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Administration Code Billing Scenario 1
Eligible client is a 4 year old child which received the influenza vaccine with counseling
Administration code billing would look like this:
Explanation
The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1st or only component the client was vaccinated for.
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Code Units Billed Charge Reimbursement
90460 1 $21.72 $21.72
Vaccine Total
Components
90460 (first/only
component)
90461 (additional
components)
Influenza 1 1 0
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Administration Code Billing Scenario 2
Eligible client is a 4 year old child which received an influenza and MMR vaccine with counseling
Administration code billing will look like this:
Explanation
The Influenza vaccine has only 1 component, only 1 unit of 90460 is reported, to indicate the 1st or only
component the client was vaccinated for. The MMR vaccine has 3 components, one unit of 90460 is
reported to indicate the 1st component, and 2 units of 90461 are reported to account for the other 2
components of the MMR vaccine. The units are combined on the claim to show 2 units of 90460 (1st
components) and 2 units of 90461 (additional components).
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Code Units Billed Charge Reimbursement
90460 2 $43.44 $43.44
90461 2 $0.00 $0.00
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Administration Code Billing Scenario 3
Eligible client is a 4 year old child which received an MMR, Varicella, and DTAP-IPV vaccine with counseling
Administration code billing will look like this:
Explanation
The MMR vaccine has 3 components, one unit of 90460 is reported to indicate the 1st component, and 2 units of 90461 are reported to account for the other 2 components of the MMR vaccine. The varicella vaccine has only 1 component, one unit of 90460 is reported to indicate the 1st/only component. The DTAP-IPV vaccine has 4 components, one unit of 90460 is reported to indicate the 1st component, and 3 units of 90461 are reported to account for the other 3 components of the DTAP-IPV vaccine. The units are combined on the claim to show 3 units of 90460 (1st components) and 5 units of 90461 (additional components).
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Code Units Billed Charge Reimbursement
90460 3 $65.16 $65.16
90461 5 $0.00 $0.00
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Vaccination Administration Codes
(19 or older, no counseling provided) Administration Codes – Face-to-Face Vaccine Counseling Not Provided
CPT
Code Description
90471
Immunization administration (includes percutaneous, intradermal, subcutaneous, or
intramuscular injection); one vaccine (single or combination vaccine/toxoid) Do not report in
conjunction with 90473.
90472 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to
code for primary procedure (90471 or 90473).
90473 Immunization administration by intranasal or oral route; one vaccine (single or combination
vaccine/toxoid) Do not report with 90471.
90474 Each additional vaccine (single or combination vaccine/toxoid). List separately in addition to
code for primary procedure (90471 or 90473).
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For vaccinations where face-to-face counseling is not provided, 90471 or 90473 is reported for the first
vaccine, and 90472 or 90474 (units combined for multiples) for each additional vaccine.
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Common Claim Denial Reasons
• Claim submitted on paper – As of July 1, 2015 all claims must be submitted electronically.
• Not submitting attachments – two ways to send attachments
• Electronically – attachments can be submitted by using the Secure Web Portal. You do not have to submit claims through the web portal in order to utilize this option. The Attachment Control Number must be filled in and match the attachment control number put on the claim.
• By Mail- when mailing in your attachments you must include the Attachment Cover Sheet. This can be found on the Medicaid Website under Forms. The Attachment Control Number must be filled in and match the attachment control number put on the claim.
• Facility or Treating Provider are not enrolled in Wyoming Medicaid.
• Both facility and treating providers must be actively enrolled with Wyoming Medicaid in order to bill for services rendered.
• Billing with Medicaid Provider number instead of NPI. Must always bill using your NPI number.
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Important Phone Numbers
IVR – 800-251-1268
Eligibility, check status, lock-in status, insurance information, claims status
Provider Relations – 800-251-1268, press 1, 5, 0 (speak to agent)
Questions concerning claims, procedure codes, eligibility, payments, verify client information, remittance advices, etc.
800-251-1268, press 3 for Web portal password resets, access to LT101 Inquiry, etc.
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Important Web Resources
Wyoming Medicaid http://wymedicaid.acs-inc.com
Medicaid provider manuals
fee schedule
Contact Us – IVR Navigation Tips
Secured Provider Web Portal
Remittance Advice
Claims Submission
LT101 Inquiry
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Questions?
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