Waiver Billing Presentation

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Waiver Billing Presentation

• Presented by the EDS Provider Field Consultants

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AgendaWelcome and Announcements

• Session Objectives
• Definition of Medicaid Waiver
• Provider Enrollment
• Member Eligibility
• Billing
• Claim Form and NPI
• Spend-down
• Paper Claim Filing Hints
• Remittance Advice
• Adjudicated Claim Information
• Claim Voids and Replacements (Adjustments)
• Helpful Tools
• Questions

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Session Objectives

• At the end of this session, providers will be
  able to
• Understand the definition of a Medicaid waiver
• Know about Indianas two new demonstration grant
  waivers
• Understand the waiver provider enrollment process
• Understand requirements necessary for a member to
  qualify for waiver services
• Understand how spend-down impacts claim
  processing
• Understand how to verify member eligibility
• Understand how to submit and adjust claims

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Definition of Medicaid Waiver

• In 1981 the federal government created Title XIX
  Home- and Community-Based Services Program.
• This act, referred to as the waiver program,
  created exceptions to, or waived traditional
  Medicaid requirements.
• A waiver is what the State government requested
  from the Centers for Medicare and Medicaid
  Services (CMS) to obtain additional funding
  through the Medicaid program - it allows for the
  provision and payment of HCBS services that are
  not provided through the Medicaid State plan.
• Medicaid waiver programs are funded with both
  state and federal dollars.
• All Indiana waiver programs have been initiated
  by the Indiana General Assembly and approved by
  CMS.

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What Is the HCBS Waiver program?

• Traditionally, Medicaid paid for
  institutional-based services only however, the
  HCBS waiver programs allowed services to be
  waived from Traditional Medicaid payment
  methodology.
• The Medicaid HCBS waivers fund supportive
  services to individuals in their own homes or in
  community settings, rather than in a long term
  care facility setting.
• The Medicaid HCBS waivers fund services to
  individuals who
• Meet the level of care specific to a waiver
• Meet the financial limitations established by
  the waiver

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What Is the HCBS Waiver program?

• In addition to waiver services, waiver members
  receive all Medicaid services under the State
  Plan (Traditional Medicaid), for which they are
  eligible.
• The State administers seven HCBS waivers and
  grants under three categories
• Nursing Facility Level of Care Waivers (includes
  three waivers/grants)
• ICF/MR Level of Care Waivers (includes three
  waivers)
• Psychiatric Residential Treatment Facilities
  Level of Care

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HCBS Waivers

• Nursing Facility Level of Care Waivers and Grant
• Administered by the Division of Aging
• Aged and Disabled Waiver (AD)
• Traumatic Brain Injury Waiver (TBI)
• Money Follows the Person Demonstration Grant
  (MFP)
• ICF/MR Level of Care Waivers
• Administered by the Division of Disability and
  Rehabilitative Services
• Developmental Disabilities Waiver (DD)
• Autism Waiver (AU)
• Support Services Waiver (SS)
• Psychiatric Residential Treatment Facilities
  Level of Care Grant
• Administered by the Division of Mental Health and
  Addiction
• Community Alternatives to Psychiatric Residential
  Treatment Facilities Demonstration Grant (CA
  PRTF)

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Community Alternatives to Psychiatric Residential
Treatment Facilities Demonstration Grant (CA-PRTF)

• Demonstration project through CMS
• Goal is to demonstrate that cost effective,
  intensive community based services can serve as
  alternative to treatment in a PRTF or assist in a
  child/youths transition back to the community
  from a PRTF
• Over 21 million federal dollars for five year
  duration
• 40 Indiana counties serve as access sites for
  grant services
• Offer eight services Wraparound Facilitation,
  Wraparound Technician, Respite Care, Non-Medical
  Transportation, Habilitation, Clinical and
  Consultative Therapeutic Services, Flex Funds,
  Training and Support for Unpaid Caregivers
• More information about services offered and
  rates www.in.gov/fssa/dmha/6643.htm

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Money Follows the Person Grant

• Demonstration program through CMS
• Helps interested individuals transition out of a
  nursing facility and into a community based
  setting
• Division of Aging and AAAs help facilitate
  transition
• Participants received waiver services plus
  additional program services
• Additional transportation
• Personal Emergency Response Systems (PERS)
• After 365 days participants transfer seamlessly
  to one of the waivers

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IFSSA Waiver Divisions

• The following divisions support the
  administration of the HCBS waivers and grants
• Developmentally Disabled, Support Services, and
  Autism Waivers
• Division of Disability and Rehabilitative
  Services402 W. Washington St., Room
  W453Indianapolis, IN 46207
• Aged and Disabled, and Traumatic Brain Injury
  Waivers, and Money Follows the Person
  Demonstration Grant
• Division of Aging402 W. Washington St., Room
  W454Indianapolis, IN 46207
• Community Alternatives to PRTF Demonstration
  Grant
• Division of Mental Health and Addiction
• 402 W. Washington St., Room W353Indianapolis, IN
  46204

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Provider Enrollment Process

• The prospective waiver provider initiates the
  waiver enrollment process by contacting one of
  the two Indiana Family and Social Services
  Administration (IFSSA) waiver divisions
• The waiver divisions coordinate a thorough
  certification process with the prospective
  provider
• A waiver provider must be certified by the
  appropriate waiver division at the IFSSA before
  EDS can process a Medicaid waiver enrollment
  application

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Provider EnrollmentProcess

• Download the IHCP Waiver Provider Application
• Visit www.indianamedicaid.com
• Go to the Provider Services tab
• Choose Provider Enrollment from the drop down
  list
• Access the link titled Enroll a New Provider in
  the IHCP
• Print the IHCP Waiver Provider Application and
  Maintenance Form
• Complete the enrollment application (original
  signatures are required)
• Avoid having your application returned. Call
  1-877-707-5750 if you have questions about the
  enrollment forms

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Provider EnrollmentMailing the Application

• The enrollment packet must include
• Completed IHCP Waiver Provider Application and
  Maintenance Form (with all applicable schedules)
• Completed IRS W-9 Form
• Waiver Approval Letter certifying the waiver
  services that the provider is approved to perform
• Mail to
• EDS Provider Enrollment, Waiver
• P.O. Box 7263Indianapolis, IN 46207-7263

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Provider Updates

• It is the providers responsibility to inform the
  IFSSA waiver divisions and the IHCP when there
  are changes to their enrollment profile
• Updates to the following information must be
  submitted to the Waiver Division at the IFSSA
  instead of EDS Provider Enrollment Department
• Waiver Specialty Change - Tax Identification
  Changes
• Name Changes - Changes in Ownership (CHOW)
• Service Location Additions
• Updates to the following information must be
  submitted to the EDS Provider Enrollment
  department
• Address changes (home office, mail-to, pay-to,
  and service location)
• Telephone number changes
• Banking information changes (if enrolled in
  electronic funds transfer)
• Requests for changes must be submitted using the
  IHCP Billing Provider Application available at
  www.indianamedicaid.com

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Member EligibilityWhere it Begins

• The Division of Family Resources (DFR)
• Enters member application into their eligibility
  tracking system known as the Indiana Client
  Eligibility System (ICES)
• Determines member eligibility status
• Makes spend-down determinations
• Maintains member information and eligibility
  files

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Waiver Program Member Eligibility

• Members Must Qualify for Waiver Program
  Eligibility
• Individuals who meet waiver Level of Care status
  and who are Medicaid eligible may be approved to
  receive waiver services.
• A limited number of slots are available for each
  waiver and the waiver slot number is approved by
  the CMS.
• A Medicaid-eligible individual cannot receive
  waiver services until
• A slot is available
• A waiver level of care is established for the
  member
• A cost comparison budget is approved
  (demonstrates cost effectiveness of waiver
  services)

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Waiver Program Member Eligibility

• Once Eligibility Requirements Are Met
• A case manager, along with the client and/or
  clients representative, as well as other service
  providers, develop a Plan of Care (POC) which is
  reviewed by the state
• The Notice of Action (NOA) lists the approved
  services for which the client may receive, along
  with the approved date span, units, and charge
  per unit
• Information from the NOA is sent to EDS for
  placement on the members Prior Authorization
  record for appropriate claims payment
• Claims pay only if PA dollars, units and services
  are available for the dates of service submitted
  on the claim

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Member EligibilityEDS Role

• Receives recipient data from (ICES)
• Updates IndianaAIM within 72 hours
• Provides and supports the eligibility
  verification systems (EVS)
• Makes EVS available 24 hours a day, seven days a
  week

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Member EligibilityHow to Verify

• There are three EVS available
• The automated voice response (AVR)
• 1-800-738-6770, or
• 317-692-0819, Indianapolis area
• Omni swipe card terminal device
• Web interChange

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Automated Voice-Response SystemEVS Using the
Telephone

• AVR provides the following
• Member eligibility verification
• Benefit limits
• Prior authorization
• Claim status
• Check write
• Contact AVR at [phone] in the Indianapolis
  local area or 1-800-738-6770

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OMNI EVS Card Reading Device

• Is cost effective for high-volume providers
• Uses plastic Hoosier Health card
• Allows manual entry
• Prints two-ply forms
• Requires upgrade for benefit limit information
  (refer to IHCP provider bulletin BT200711)
• See Chapter 3 of the IHCP Provider Manual for
  more information.

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Web interChangeEVS Using the Internet

• The following is available through Web
  interChange
• Member information available by Member ID, SSN,
  Medicare Number, or Name and DOB
• Spend-down information
• DFR information
• Detailed TPL information
• Online TPL update requests
• Web interChange is accessible via
  www.indianamedicaid.com

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Waiver Billing

• Notice of Action
• Lists the approved service provider
• Lists the approved service codes
• Gives the approved units and dollar amounts
• CMS-1500 claim form
• Use service code approved on the NOA
• Include all modifiers listed with the service
  code
• Refer to the HCBS Waiver Program Provider Manual
  for information regarding
• Service Definitions
• Allowable Services
• Service Standards
• Documentation Standards

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Authorized Services

• You may only bill for authorized services. In
  order for services to be authorized they must
• Meet the needs of the member
• Be addressed in the members Plan of Care (POC)
  and/or Individualized Support Plan (ISP)
• Be provided in accordance with the definition and
  parameters of the service, as established by the
  waiver

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Claim Form and NPI

• Waiver providers use the CMS-1500 claim form when
  submitting paper claims for services
• The NPI is not needed for waiver providers who do
  not perform healthcare services
• Waiver providers may submit claims using their
  legacy provider identifier (LPI) as they have in
  the past
• Waiver providers do not report or use a taxonomy
  code
• Note Targeted case managers who provide
  traditional Medicaid services for determining the
  waiver level of care should report and use their
  NPI

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Spend-down

• Spend-down is assigned by the Division of Family
  Resources at the time of the eligibility
  determination
• Only the member and county are aware of the
  spend-down amount
• EDS credits the members spend-down based on the
  usual and customary charge billed on the claim
• Spend-down is credited on claims based on the
  order they are processed
• ARC 178 appears on the remittance advice when
  spend-down is credited on claims
• Providers may bill the member for the amount
  listed beside ARC 178
• Member is responsible to pay upon receipt of the
  Spend-down Summary Notice

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Paper Claim Filing Helpful Hints

• Use the approved version of the CMS-1500
  Claim Form
• Do not use staples or paper clips
• Verify that the claim form is signed, or complete
  the Attestation for Signature on File
• Send claims to
• EDS Waiver Program Claims
• P.O. Box 7269
• Indianapolis, IN 46207-7269
• Review the remittance advice (RA) closely

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Remittance Advice Statement with claims
processing information

• RAs provide information about claims processing
  and financial activity related to reimbursement
• RAs contain Internal Control Numbers (ICNs) with
  detail level information
• RAs give detail status (paid or denied)
• RAs give payment amount
• See the IHCP Provider Manual, Chapter 12 for more
  details
• Most Common Waiver Claim Denials
• 2013 Recipient Ineligible for Level of Care
• 3000 Units exceed PA Master
• 3001 DOS Not on PA Master File
• 5000 Possible Duplicate

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Adjudicated Claim InformationInternal Control
Number

• The Internal Control Number (ICN) is a 13-digit
  number assigned to each claim
• The region tells how the claim was submitted
• 20 is for electronic with no attachments
• 21 electronic with attachments
• 10 paper with no attachments
• 11 paper with attachments
• 50 voids/replacements noncheck-related

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Claim AdjustmentsVoids and Replacements

• Replacement is a HIPAA-approved term used to
  describe the correction of a claim that has
  already been submitted
• Replacements can be performed on paid, suspended,
  and denied claims
• Denied details can be replaced or billed as a new
  claim
• To avoid unintentional recoupments, submit paper
  adjustments for claims finalized more than one
  year from the date of service
• Void is the term used to describe the deletion
  of an entire claim
• Voids can be performed on paid claims only
• Voids and replacements can be performed to
  correct incorrect or partial payment, including
  zero dollar amount
• Note Paper replacements can only be processed
  on paid claims.

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Helpful ToolsAvenues of Resolution

• IHCP Web site at www.indianamedicaid.com
• IHCP Provider Manual (Web, CD-ROM, or paper)
• HCBS Waiver Provider Manual
• Customer Assistance
• 1-800-577-1278, or
• [phone] in the Indianapolis local area
• Written Correspondence
• P.O. Box 7263Indianapolis, IN 46207-7263
• Provider Relations Field Consultant
• View a current territory map and contact
  information online at www.indianamedicaid.com

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Helpful ToolsAdditional Avenues of Resolution

• Division of Disability and Rehabilitative
  Services402 W. Washington St., Room
  W453Indianapolis, IN 46207
• Division of Aging402 W. Washington St., Room
  W454Indianapolis, IN 46207
• Division of Mental Health and Addiction402 W.
  Washington St., Room W353Indianapolis, IN 46204

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• Questions