ALABAMA MEDICAID TRAINING

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ALABAMA MEDICAID TRAINING

• Billing and Policy Changes

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• Utilization Review Policy and Reimbursement for
  Inpatient Hospital Admissions and Concurrent Stays

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Outpatient Observation

• Medicaids Outpatient Observation Policy has not
  changed.
• All Outpatient Observation Services billed must
  have received care through the Emergency
  Department first in order to bill for Outpatient
  Observation Services.

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Inpatient Utilization Review

• All Instate and Border Hospitals will utilize
  Alabama Medicaid Adult and Pediatric Inpatient
  Care Criteria (SI/IS) for utilization review,
  billing and reimbursement purposes.

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Physician Advisor

• It is the responsibility of each hospital to
  utilize their physician advisor.
• This refers back to the reference in 42 C.F.R.
  456, Subpart C.

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Physician Change Order

• The attending physician or resident may change an
  order up to 30 days after the patient has been
  discharged as long as the patient met/meets
  current Adult and Pediatric SI/IS criteria.

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InterQual Adult and Pediatric Medical Criteria
and Alabama Medicaid Local Policy

• For admissions and continued stays on or after
  July 1, 2010, Medicaid will require Instate and
  Border Hospital Providers to report dates of
  services that do not meet InterQual Adult and
  Pediatric Medical Criteria and Alabama Medicaid
  Local Policy on the UB-04 claim form.

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Reporting InterQual Dates on the Claim

• Hospital Providers will be required to use
  Occurrence Span Code 74 to identify days not
  meeting InterQual Adult and Pediatric Medical
  Criteria and Alabama Medicaid Local Policy.
• AND
• Enter the occurrence span dates for the dates
  that do not meet InterQual Adult and Pediatric
  Medical Criteria and Alabama Medicaid Local
  Policy.

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Psychiatric and Rehabilitative Services

• Inpatient Psychiatric and Rehabilitative Services
  in an acute care facility will be exempt from
  reporting dates of service that do not meet
  InterQual Adult and Pediatric Medical Criteria
  and Alabama Medicaid Local Policy.

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Outpatient Billing and Encounter

• Medicaid anticipates moving toward an encounter
  Outpatient Hospital service although this will
  not occur until the State Plan has been approved
  for the hospital tax assessment.

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Outpatient Encounter (continued)

•  
• All billing rules for outpatient claims will
  still apply.
• The remittance advice (RA) will look the same
  except an encounter procedure code (T1015) will
  be added for the encounter payment.

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Definition of Encounter

• Outpatient Hospital encounters are generally
  face-to-face contacts between a patient and a
  health professional for medically necessary
  services.
• An encounter may also be classified as
  non-patient hospital services such as specimens
  and blood samples sent to the hospital for
  performance of tests.
• Claims for ER and noncertified outpatient visits
  should be all inclusive.
• Physicians orders that request services to be
  provided over an established period of time,
  should be span billed monthly, on one claim.
  Examples of repeat services provided over an
  established period of time are chemotherapy,
  radiation services, and physical therapy
  services.
• Each hospital should continue to bill as they did
  prior to implementation of the encounter payment
  methodology.
• One encounter rate will be paid per ICN (internal
  control number).

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NDC Requirement

•  Question being sent to CMS for an answer.

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CURP

• Medicaid is in the process of developing a CURP
  manual to identify length of stay days.
• This manual will be available on the website by
  July 1, 2010.

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Further Questions

• ?

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Contact Information

• Jerri.jackson_at_medicaid.alabama.gov
• Karen.watkins-smith_at_medicaid.alabama.gov