provider manual summary of updates 9/1/2012 – 6/30/2009

HP Enterprise Services

PROVIDER MANUAL SUMMARY OF UPDATES 9/1/2012 – 6/30/2009

CMS-1500 SUPPLEMENT SUMMARY OF UPDATES 9/1/2012 – 6/5/2009

UB-04 SUPPLEMENT SUMMARY OF UPDATES 9/1/2012 – 6/10/2009

PA SUPPLEMENT SUMMARY OF UPDATES 9/1/2012 – 7/14/2009

9/13/2012 Green Mountain Care ~ Detailed Summary of Updates of 98

TABLE OF CONTENTS PROVIDER MANUAL DETAILED SUMMARY OF UPDATES 9/1/2012 - 06/30/2009 ........................................... 3

CMS-1500 SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/13/2012 – 6/5/2009 .................................... 37

UB-04 SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/1/2012 – 6-10-2009 ........................................... 67

PA SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/1/2012 – 7-14-2009 ................................................ 84


PROVIDER MANUAL DETAILED SUMMARY OF UPDATES

*Please note: -Sections below containing text in red font are additions to current policy. Previous verbiage will be noted, when applicable). -Section

9/1/2012 - 06/30/2009

headings

**************************************************************************************

below in red font are new sections*

1.1.8 CLAIM EDIT STANDARDS

Vermont Medicaid adheres to the following edit standards:

(page 15)

· AMA, CPT, HCPCS and NCCI;

· National Specialty Edit Standards; or

· Proprietary NCPDP-compliant pharmacy adjudication software provided through our Prescription Benefit Management(PBM) Catamaran ® and

· Other appropriate nationally-recognized edit standards, guidelines or conventions approved by the commissioner.

Added

******************************************************************************

: above red text to section

1.3.5 CO-PAYMENTS

Certain beneficiaries must participate in the cost of care for services. Co-payments are

(page 35)

never required of Medicaid beneficiaries under age 21 (effective 8/1/2012); pregnant or in a 60-day post-pregnancy period; living in a long-term care facility, nursing home or hospice; or for family planning services and supplies and emergency services.

Added

******************************************************************************


(8/1/2012)

1.1.8 CLAIM EDIT STANDARDS

Vermont Medicaid adheres to the following edit standards:

(page 15)

CPT, HCPCS and NCCI;

National Specialty Edit Standards; or

Other appropriate nationally-recognized edit standards, guidelines or conventions approved by the commissioner.

Added

******************************************************************************


1.3 BENEFICIARY INFORMATION"Beneficiary" is the term used to refer to a person who has been determined eligible for and enrolled in one of the Vermont Medicaid programs. Eligibility is determined at a district office of the Vermont Department for Children and Families, including the Health Access Eligibility Unit in Waterbury, based on a review of the

(page 29)


applicant's needs, income and resources. The various Vermont Medicaid programs have differing eligibility requirements and benefits.

Each Beneficiary is assigned a unique identification number (UID) and receives a Green Mountain Care member card. The UID number will be 1 to 8 digits in length. Enter the UID number on your claim exactly as it is shown on the beneficiary's card.

When submitting an electronic claim for a beneficiary with a one digit Unique ID Number insert a zero in front of the single digit UID (04, 05, 06 and etc.); to allow the claim to be accepted. This instruction does not apply to paper claims.

Added**************************************************************************************


1.3.5 CO-PAYMENTS

Certain beneficiaries must participate in the cost of care for certain services. Co-payments are

(page 35) never required

of Medicaid patients living in a nursing home, under age 18 21(effective 8/1/2012), pregnant, or women in their 60-day post-pregnancy period. No co-payment is assessed for services to CRT patients in a mental health center. The amounts for the various services follow:

Medicaid Co-Pays

$1.00 for prescriptions of $29.00 or less $2.00 for prescriptions of $30.00 to $49.99 $3.00 for prescriptions of $50.00 or more $1.00 - for prescription drugs and DME/medical supplies costing less than $30.00 (effective 8/1/2012); $2.00 - for prescription drugs and DME/medical supplies costing $30.00 or more but less than $50.00 (effective 8/1/2012); $3.00 - for prescription drugs and DME/medical supplies costing $50.00 or more (effective 8/1/2012). $3.00 - per dental visit for adult’s age 21 or older $3.00 - per day for hospital outpatient services $75.00 - per inpatient hospital admission

:

*Effective 07/01/03:* No inpatient, outpatient or pharmacy co-pays for ANFC related beneficiaries for ages 18-20 (previous to 07/01/03, All Medicaid beneficiaries had a co-payment at age 18 and up). AID CATEGORIES: AC, AR, BC, BG, CO, CC, CP, CR, DC, DR, FC, GC, GR, HC, HR, IC, IR, KZ, MC, MR, NC, NR, OC, PC, PR, RR, TC, TR, XC, XR, YC

*Effective 07/01/03: Inpatient co-pay for SSI related beneficiaries beings at age 18 AID CATEGORIES: AA, AB, AD, AZ, BA, BB, BD, BP, C1, C2, CG, C3, CC, DA, DD, EA, EB, EC, ED, ER, GA, GE, HA, HB, HD, HT, HV, HZ, IA, ID, KC, LA, LB, LC, LD, LR, LZ, MA, MB, MD, MH, MP, NA, NB, ND, NP, P1, PA, PB, PD, PP, Q1, Q2, QA, QD, QW, SC, SP

*Effective 07/01/03: No inpatient co-pays for ANFC related beneficiaries for ages 18-20 (Previous to 07/01/03, All Medicaid beneficiaries had a co-pay at age 18 and up). AID CATEGORIES: A5, A8, B5, BH, C4, C5, C7, C8, D5, D8, F5, G5, G8, H5, H8, I5, K9, M5, M8, O5, P5, P8, R1, T5, T8, X5, X8, Y5

VHAP Co-Pays:


$1.00 - for prescription drugs (at or above 100% FPL) and DME/medical supplies costing less than $30.00 (effective 8/1/2012); $2.00 - for prescription drugs (at or above 100% FPL)and DME/medical supplies costing $30.00 or more but less than $50.00 (effective 8/1/2012); $3.00 - for prescription drugs(at or above 100% FPL) and DME/medical supplies costing $50.00 or more (effective 8/1/2012). $3.00 – outpatient hospital visits (effective 8/1/2012); $25.00 – Emergency room visits

VHAP co-pays apply regardless of beneficiary age. AID CATEGORIES: J3-J8, U1-U6, UX, UA, UB, UC, UD, UE & UF.

VHAP Primary Care Plus Beneficiaries-Aid Categories J3-J8, U1-U6 and UX: 7/01/2012 Green Mountain Care ~ Provider Manual Page 36 of 113 Effective 01/01/04: Co-pays are eliminated for all services, with the exception of $25.00 for medically necessary emergency room visits. VHAP Limited Beneficiaries-Aid Categories UA, UB, UD, UE & UF: Effective 01/01/04: Co-pays are eliminated for all services, with the exception of $25.00 for medically necessary emergency room visits. Added: above red text to section

Deleted:**************************************************************************************

strikethrough text

4.2.1 ADJUSTMENT REQUESTS & TIMELY FILINGProviders can request adjustments and recoupments to claims billed incorrectly that result in a negative financial outcome for the provider within three years of the original date of service; the entire claim will be recouped. Partial recoupment requests are to be submitted as refunds. If the claim is more than three years old, the provider must refund the overpayment by completing the refund form and attaching the refund check. The Refund form is available on our website at

(page 80)

https://vtmedicaid.com/Downloads/forms.html.

Added**************************************************************************************


(7/1/2012) 1.3.5 CO-PAYMENTS (page 36)

VHAP Limited Beneficiaries

Effective 01/01/04: Co-pays are eliminated for all services, with the exception of $25.00 for medically necessary emergency room visits.

-Aid Categories UA, UB, UD, UE & UF:

Submit attachments with claim and note the beneficiary’s program eligibility is Z9.

Exception: Beneficiaries in Aid Category Z9 have only emergency inpatient benefits.

Added**************************************************************************************


2.2.6 REFERRAL PROVIDERS (page 51)


Referral of PC Plus beneficiaries can be made to any provider currently enrolled in the Vermont Medicaid program.

Effective July 1, 2012, non-emergency (elective) out-of-state medical visits will require prior authorization from the DVHA Clinical Unit. Enrolled border hospitals are excluded from this requirement. In network referring providers must submit requests using the Out-of-state Elective Office Visit Request Form located at http://dvha.vermont.gov/for-providers/forms-1. Fax requests to 802-879-5963.

Added**************************************************************************************


(6/1/2012)

1.3.12 THIRD PARTY LIABILITY (TPL) / OTHER INSURANCE (OI

OI Blanket Denials – Providers are required to submit blanket denials from a primary insurer to HPES every calendar year. For example: A blanket denial issued on July 7, 2012, will only be valid until December 31, 2012 and a new denial will be required as of January 1, 2013.

) (page 39)

Obtaining a blanket denial every calendar year will inform HPES of any changes made to a recipient’s primary insurance coverage.

Added**************************************************************************************


1.3.17 BENEFICIARY APPEAL PROCESS

For additional information, refer to the Health Care Programs Handbook at

(page 44)

http://dvha.vermont.gov/for-consumers, Member Services, Handbooks section.

Added**************************************************************************************


3.1.2 SPECIAL FUNCTION KEYS

Since the telephone touch-tone keypad has only numeric digits 0-9, a special method must be used to allow users to enter alphabetic characters. To enter alphabetic data, press the asterisk key (*) followed by a two-digit numeric code. This numeric code represents a specific alphabetic character. The first digit corresponds to the key cap number on which the character appears. The second digit corresponds to one of the three alphabetic characters on the key cap. Therefore, the code “*21” is used to input the letter “A” since the “A” appears in position one on key cap, two on the touch-tone keypad.

Alphabetic Data

The characters “Q” and “Z” do not appear on the touch-tone keypad. Therefore, these two characters are treated as though they are the first two characters on key cap one. To enter “Q”, the user enters “*11”. To enter “Z”, the user enters “*12”. Deleted**************************************************************************************

: above section from Appendix

3.1.3

Since the telephone touch-tone keypad has only numeric digits 0-9, a special method is used to allow entry of alphabetic characters. To enter alphabetic data, press the asterisk key (*) followed by a two-digit numeric code. This numeric code represents a specific alphabetic character.

ALPHA TO NUMERIC CONVERSIONS

http://dvha.vermont.gov/for-providers/forms-1.%20Fax%20requests%20to%20802-879-5963�

http://dvha.vermont.gov/for-consumers�

http://dvha.vermont.gov/for-consumers�


A=*21 B=*22 C=*23 D=*31 E=*32 F=*33 G=*41 H=*42 I=*43 J=*51 K=*52 L=*53 M=*61 N=*62 P=*71 Q=*11 R=*72 S=*73 T=*81 U=*82 V=*83 W=*91 X=*92 Y=*93 Z=*12

Note: There is no alpha O listed above because provider numbers containing alpha characters followed by a zero should be a “zero” NOT an alphabetic character.

Deleted**************************************************************************************

: above section from Appendix

3.3 AID CATEGORY LISTING

(Identifies beneficiary program eligibility) (page 65)

Medicaid Managed Care YES

A3, A4, A5, A6, A8, A9, B3, B4, B5, B6, B7 B8, BH, C4, C5, C6, C7, C8, C9, CH, D5, D8, E5, E8, F5, G 5, G8, H3, H4, H5, H6, H8, H9, I5, I8, K5, K9, L3. L4, L5, L6, L8, L9, M3, M4, M5, M6, M7, M8, O5, P2, P3, P4, P5, P6, P7, P8, P9, Q3, Q6, R1, R4, R6, R7, R9, RG, RI, RK, S5, S7, T5, T8, W3, W4, W6, W9, X3, X4, X5, X6, X8, Y5

Added**************************************************************************************

: above red text to Appendix

(4/1/2012) 1.1.5 GLOSSARY OF TERMS AND PHRASES

IDENTIFICATION NUMBER-A unique number assigned to each Vermont Medicaid Beneficiary that may be referred to as the UID or MID. The number appears on the beneficiary’s Green Mountain Care Card.

(page 10)

Added**************************************************************************************


1.3.9 SPEND-DOWN

The following aid category codes indicate Notice of Decision (Spend Down) applies to services provided on the first day of a beneficiary’s eligibility: PA, PB, PC, PD, PP PR, P3, P4, P5, P6, P7 and P8.

(page 39)

Added**************************************************************************************



4.1 REMITTANCE ADVICEProviders are responsible for maintaining the information furnished in the banner pages.

(page 66)

Deleted: above text Added**************************************************************************************

: The banner page of the RA provides important information about policy and billing.

4.1.1 BANNER PAGE

It is recommended that each provider retain copies of the banner pages, use them to update their Provider Manuals and consult the banner Page whenever a question arises regarding DVHA policy or procedure. Banner pages are available weekly with RAs and posted online weekly at

(page 66)

http://vtmedicaid.com/Information/whatsnew.html and are archived at the same online location.

Deleted

: Deleted strikethrough text

Added**************************************************************************************

: red text

(3/1/2012) 1.1.7 IMPORTANT ADDRESSES AND TELEPHONE NUMBERS

103 South Main Street Waterbury, Vermont 05671-1201 Tel: (802) 241-2880 Fax: (802) 241-2897

(page 15)

Deleted: above address; replaced with below address

289 Hurricane Lane Williston, Vermont 05495 Tel: (802) 871-3350 Fax: (802) 871-3281 **************************************************************************************

1.2.15 RIGHTS AND RESPONSIBILITES

· May not treat a Vermont Medicaid beneficiary any differently than a patient with other payer sources.

(page 25)

Added**************************************************************************************


1.3.17 BENEFICIARY APPEAL PROCESS

While the provider does not have the right to appeal; beneficiaries may ask for review of certain actions (listed below) if they disagree with the action. For decisions made by DVHA, a request for an appeal or fair hearing may be requested through Member Services for Green Mountain Care by calling 1-800-250-8427 or by letter to: Green Mountain Care Member Services, Department of Vermont Health Access, 101 Cherry Street, Suite 320, Burlington, VT 05401. Requests must be made within 90 days from the decision date and appeals are heard by a qualified person not responsible for the original decision.

(page 44)

A provider may ask for an appeal on behalf of the beneficiary, if requested to do so by the beneficiary. In most instances, a decision will be made within 45 days of the appeal request. In some instances, the process

http://vtmedicaid.com/Information/whatsnew.html�


can be extended up to an additional 14 days; however, a decision will always be made within 59 days of the appeal request.

If the need for the denied benefit is an emergency, an expedited appeal may be requested. If after review it is determined that the appeal is an emergency, a decision will be made within three business days.

The following actions may be appealed:

· Denial or limit of a covered service or eligibility for service, including the type, scope or level of service;

· Reduction, suspension or termination of a previously approved covered service or a service plan;

· Denial, in whole or in part, of payment for a covered service;

· Failure to provide a clinically-indicated covered service, by any provider;

· Failure to act in a timely manner when required by State rule;

· Denial of a request to obtain covered services from a provider who is not enrolled in Medicaid (note that the provider who is not enrolled in Medicaid cannot be reimbursed by Medicaid).

Beneficiaries with an employer –sponsored insurance plan may call the customer service number on the back of their ID card to obtain information on appealing a decision made by that plan.

When a beneficiary is told that the benefit has changed because of a change in a federal or state law, the beneficiary may not ask for an appeal but may request a fair hearing.

Added**************************************************************************************

: the above section

1.3.18 FAIR HEARING

A beneficiary that disagrees with the appeal decision may request a fair hearing by the department responsible for the decision. The request must be made within 90 days from the date of the original notice of decision or action, or 30 days from the date of an appeal decision.

(page 45)

Added**************************************************************************************

: the above section

1.4.5 PROVIDER RELATIONS FIELD REPRESENTATIVE

The Provider Relations staff employs field representatives who are available (at no cost to the provider) to travel throughout the state for problem solving and provider education.

(page 48)

Added**************************************************************************************


(2/1/2012) 1.1.3 MANUALS, MEDICAID RULE AND STATE PLAN RESOURCES

The State Plan, a guiding document for changes applicable to Vermont’s Medicaid population and includes the populations for the State’s Children’s Health Insurance Program (SCHIP) and the Choices for Care program which are not covered by the Global Commitment (GC) to Health Waiver. State Plan information, is at

(page 7)

http://dvha.vermont.gov/administration in the Service Administration section. Global Commitment to Health 1115 Demonstration Waiver information is also at http://dvha.vermont.gov/administration in the Global Commitment section.

Added: red text

http://dvha.vermont.gov/administration�

http://dvha.vermont.gov/administration�


Deleted: section name, 1.1.3 **************************************************************************************

MANUAL AND RULE ACCESSIBILITY

1.1.5 GLOSSARY OF TERMS AND PHRASES

PROVIDER ENROLLMENT AGREEMENT

(page 10)

Deleted

**************************************************************************************

: Providers that have the power to prescribe and refer but not bill for services, may enroll as a non-participating provider.

1.2.4 ENROLLMENT AND CERTIFICATION

Enrollment is limited to the following:

(page 20)

Note: Non-participating enrollment is no longer accepted.

Added: above red text

Deleted

**************************************************************************************

: Non-participating providers enroll in order to have prescriptions for Vermont Medicaid beneficiaries recognized even though the non-participating provider cannot bill Vermont Medicaid.

1.2.7 DOCUMENTATION OF SERVICES

All documentation must be legible, contain all required information and applicable dates.

(page 21)

Added**************************************************************************************

: red text to section

1.1.11

Non-participating physicians, if enrolled, can:

NON-PARTICIPATING PROVIDERS

-Be a referring physician on the CMS 1500 and UB-04 claims -Write an RX under his/her own NPI number -Sign a MNF for DME or medical supplies

Deleted**************************************************************************************

: section from manual

1.2.8 NON-PARTICIPATING PROVIDER

Some physicians that cannot or do not wish to submit claims for services (such as hospital residents) but they need to be identified for the purpose of referring or prescribing. The DVHA needs HPES to assure that all prescribing physicians are licensed and acting within the scope of their license.

Therefore, a physician may be enrolled as a non-participating provider and assigned a number for use in the above instances only. Enrolling as a non-participating physician, assures that other participating providers and facilities may be reimbursed for such prescribed services or items. A non-participating physician may not submit claims for payment for services. The Non-Participating Enrollment Agreement must be used by physicians who wish to be assigned a Vermont Medicaid provider ID number to be a referring or prescribing physician, even if they do not wish to submit claims for services.

Deleted**************************************************************************************

: section from manual

1.3.9 SPEND-DOWN (page 38)


Providers may obtain a copy of the spenddown notification by contacting the DCF Call Center at 800-479-6151 or Member Services for Green Mountain Care. The case worker will be notified of the request and will provide the information.

Added**************************************************************************************

: above red text

1.4.4 LOCUM TENENS (page 46)

Added: The Locum Tenens physician must be licensed in Vermont and be actively enrolled in Vermont Medicaid.

Added: The Billing provider is 100% liable for all locum tenens billing.

Deleted:, usually hired from out of state,

Deleted

**************************************************************************************

: If a Locum Tenens physician is covering for a physician who has permanently left a practice, then the Locum Tenens physician must enroll with Vermont Medicaid.

1.4.9 FORMS AND MANUALS (page 48)

Deleted

(1/1/2012)

: the Non-Participating Provider Signature Page listed under Provider Enrollment Forms. **************************************************************************************

1.3.13

If a provider decides at any point to bill Vermont Medicaid, the provider must withdraw the claim to the workers compensation/auto insurer. The withdrawn claim is still subject to the six-month timely filing limit. Vermont Medicaid will pay the claim and bill the responsible insurance provider. Payments made by the insurance provider will come directly to Vermont Medicaid. No reimbursement will be made to the provider.

WORKERS COMPENSATION/ACCIDENT LIABILITY BILLING

Added**************************************************************************************

: above red text to paragraph

(11/1/2011)

1.1.15 REIMBURSEMENT OF OVERPAYEMENTS

Providers are reminded of the 2009 Fraud Enforcement and Recovery Act (FERA) which amended the False Claims Act, 31 U.S.C §§3729-3733, by increasing the scope of the false claims liability to include persons who knowingly conceal the retention of any overpayment of government money and the 2010 Patient Protections and Affordable Care Act (PPACA) which directly linked the retention of overpayments to false claims liability. PPACA requires the report and return of all overpayments within 60 days after the date on which the overpayment was identified or the date the corresponding cost report was due, whichever is later. Additionally, providers must submit notification in writing as to the reason of the overpayment. HPES will forward any cases in which the discovered overpayment was not refunded during the timeline mandated by PPACA to the DVHA Program Integrity Unit for their review.

(page 18)

Hospitals (in addition to the above information) HPES contracts with AIM HealthCare to audit hospitals for credit balances on accounts. This arrangement does not negate the provider's responsibility to report and return overpayments timely. HPES will forward any cases in which the discovered overpayment was not refunded during the timeline mandated by PPACA to the DVHA Program Integrity Unit for their review.


Added**************************************************************************************

: above red text

1.2.7 DOCUMENTATION OF SERVICES

Each provider must keep written documentation for all services that have been performed for beneficiaries. Providers must be prepared to submit information on transactions upon request of the State Agency or HHS secretary for records of any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5 year period ending on the date of the request, within 35 days; this includes the actual case record notes for any services performed.

(page 21)

Added

1.2.23

: above red text **************************************************************************************

UTILIZATION REVIEW

The DVHA conducts numerous utilization management and review activities. Reviews are intended to assure that quality services are provided to beneficiaries and that providers are using the program properly. The reviews are generally an examination of records, known as a desk audit, although they may also include an on-site visit from the utilization review unit.

(page 28)

DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based on sound medical evidence. Approved criteria include the following:

· McKesson Health Solutions InterQual® Guidelines;

· DVHA Clinical Guidelines;

· Vermont State Medicaid Rules;

· Hayes and Cochrane New Technology Assessments; and

· Other Nationally Recognized Evidence Based Criteria

McKesson Health Solutions InterQual® Guidelines are now available to providers behind the Vermont Medicaid secure provider web portal at www.vtmedicaid.com/secure/logon.do.

DVHA Clinical Guidelines and Vermont Medicaid State Rules will continue to be available at the DVHA website at dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

Added**************************************************************************************


1.3.2 HEALTH CARE BENEFIT PROGRAMS (page 30)

VHAP Pharmacy The VHAP Pharmacy program was created to expand pharmaceutical and vision benefits to low-income, elder or disabled residents of Vermont. The program covers prescription drugs and certain over the counter drugs. Co-payments are required, see Section 1.3.4.

Replaced**************************************************************************************

: the word eyeglass with vision

1.3.5 CO-PAYMENTS

AID CATEGORIES: AA, AB, AD, AZ, BA, BB, BD, BP, C1, C2, CG, C3, CC, DA, DD, EA, EB, EC, ED, ER, GA, GE, HA, HB, HD, HT, HV, HZ, IA, ID, KC, LA, LB, LC, LD, LR, LZ, MA, MB, MD, MH, MP, NA, NB, ND, NP, P1, PA, PB, PD, PP, Q1, Q2, QA, QD, QW, SC, SP

(page 35)

Added: above red text to section paragraph

http://www.vtmedicaid.com/secure/logon.do�

http://ovha.vermont.gov/for-providers/clinical-coverage-guidelines�


**************************************************************************************

(10/1/2011) 1.2.7 DOCUMENTATION OF SERVICES

The documentation for any service that was billed must be kept for seven years.

(page 20)

Replaced**************************************************************************************

: the word six with seven

1.2.13 INDIVIDUAL CONSIDERATION/MANUAL PRICING

Providers wishing to request updates to any of the following: place of service, provider type, provider specialty modifier/code combination additions and diagnosis rate review are advised to e-mail their request to

(page 24)

[email protected]. Providers must include the following information: the ICN of the denied claim (required), the complete name of the person initiating the request, the specific code, attribute to be updated, provider name and number.

All unit requests must include a brief cover letter containing the following information: ICN of the denied claim (required), complete name of the person initiating the request, units requested, the specific code and the provider name & number. Other required items include: Hard copy of the claim, notes and all medical journal articles sustaining your request. Mail to: HP Enterprise Services, 312 Hurricane Lane, Williston, VT 05495, Attn: HIPAA Request Reviewer.

Added**************************************************************************************


3.1.1 INFORMATION AVAILABLE (page 54)

-Last dental oral exam

Service Limitations when exhausted:

Added**************************************************************************************

: above red text

(9/1/2011) 1.2.22 TIMELY FILING

Providers submitting a timely filing appeal request containing 10 or more claims, all with the same late submission reason, are required to complete and the Timely Filing Appeal Listing-10 or more claims document, located at

(page 27)

www.vtmedicaid.com/Downloads/forms.html.

A request for an exception can be made by sending the claim with a detailed explanation of why an exception should be granted, along with any other required attachments to:

Added**************************************************************************************


1.3.2 HEALTH CARE BENEFIT PROGRAMS (page 29)

VHAP-Limited VHAP Limited mirrors VHAP Managed Care, i.e., PC Plus. Physician referrals or Prior Authorizations required for Managed Care are also required for VHAP Limited; therefore, a beneficiary may need to select a Primary Care Physician (PCP) prior to receiving a service. If a beneficiary pays their initial premium, coverage is retroactive to the day eligibility was approved. The beneficiary will be responsible for the cost of services, however, if the initial premium is not paid.

mailto:[email protected]�

http://www.vtmedicaid.com/Downloads/forms.html�


VHAP-LimitedPC Plus. As soon as beneficiaries are determined eligible and pay any required premium, they

VHAP Limited is a transition program used prior to enrollment in managed care,

are covered for certain services on a fee-for-service basis. The VHAP Limited benefit is more limited than PC Plus. In general, physician services, inpatient and outpatient hospital services as well as prescription drugs are covered. VHAP Limited beneficiaries are issued a Green

Replaced**************************************************************************************

: VHAP-Limited paragraph with above red text


Added: 340-B Drug Program: Provider Enrollment Amendment, Contact Information Sheet & Provider Presentation and the Timely Filing Appeal Listing Deleted**************************************************************************************

: the Vision Eligibility Verification Request Fax Form

SECTION 2-VERMONT HEALTH ACCESS PLAN- PC PLUS (page 48)

VHAP Limited provides a

Introduction

limited benefit to low income uninsured adults. This is a transition program between initial enrollment and enrollment in managed care. The other program, VHAP Pharmacy, provides pharmacy benefits for low income Vermonters who are elderly or disabled.

Deleted**************************************************************************************

: limited (as underlined in above text)


PROGRAM

(page 64)

DENTAL AID CATEGORIES

VPharm with Crossovers NO VG. VH, VI (Crossovers are Medicare, co-insurance and deductable claims)

VHAP Pharmacy with Crossovers NO V4 (see above for explanation of Crossovers)

Added**************************************************************************************

: above red text to the Aid Category Listing chart

(8/2/2011) 1.2.11 PAYMENT-DVHA PRIMARY (page 23)

Psychologist - Reimbursement basis is the lower of the provider’s charges or 110% of Vermont Medicaid allowed rate on file. The unit of service is time (15 minutes, 30 minutes, 60 minutes) Master Level Psychologist/Counselor - Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on file. The unit of service is time (15 minutes, 30 minutes and 60 minutes).

Deleted: above text from section

Psychological Services: see CMS-1500 (PSYCHIATRY/PSYCHOLOGY)



**************************************************************************************

(8/1/2011) 1.2.11 PAYMENT-DVHA PRIMARY (page 22)

Anesthesia Assistants-Reimbursement basis is 80% of the Vermont Medicaid rate on file.

Certified Nurse-Midwife-Reimbursement basis is 100% of the Vermont Medicaid rate on file.

CRNA-Reimbursement basis is 100% of the Vermont Medicaid rate on file.

Added: red above text

Deleted: Anesthesia Assistants-Reimbursement basis is for the procedure at 100% of the CRNA 50%

Deleted: Certified Nurse-Midwife-Reimbursement basis is the lower of the provider’s charges or ninety percent (90%) of Vermont Medicaid rate on file for a physician providing the same service. Reimbursement is limited to only certain procedure codes.

Deleted: CRNA

**************************************************************************************

-Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on file for the procedure code at 50%.

3.4 2009 AID CATEGORY LISTING

Medicaid Managed Care R4, R6, R7, R9, RG, RI, RK,

(page 64)

Traditional Medicaid RF, RH, RJ, RP, R0, R2, R3,

Added**************************************************************************************


(7/1/2011) 1.1.9 CONTRACTUAL ALLOWANCE

If the entire allowed amount is applied to the primary insurance deductable do not enter the contractual allowance.

(page 16)

Added**************************************************************************************


1.2.1 PROVIDER TAX

Lockbox State of Vermont State Agency of Human Services Supplemental/Tax Assessment PO Box 1335 Williston, VT 05495

(page 18)

Deleted: DVHA cash coordinator, 312 Hurricane Lane, Suite 201, Williston, VT 05495

Added**************************************************************************************

: above red text

1.3.5 CO-PAYMENTS (page 36)

VPharm Pharmacy-Aid Categories VD, VE, VF, VG, VH, VI, VK, VL, VM, VN & VO:



**************************************************************************************

1.4.3 GUIDELINES FOR BILLING INCIDENT TO (page 44)

Deleted**************************************************************************************

: Note: Drug management cannot be billed “incident to”.

2.3.1 REFERRALS (page 51)

Deleted**************************************************************************************

: or the DVHA referral form from section

(6/1/2011) 1.4.9 FORMS AND MANUALS

The forms and manuals used in the Vermont Medicaid program are available for download from Vermont Medicaid web portal at

(page 46)

www.vtmedicaid.com. A Provider Directory of Resources is available for download at https://vtmedicaid.com/Information/whatsnew.html. The following documents can be printed directly from the website:

Added**************************************************************************************


SECTION 2-VERMONT HEALTH ACCESS PLAN- PC PLUS PCPs receive a monthly case management fee for each member enrolled with the PCP. This fee is for coordinating members’ health care services, regardless of whether the member is seen. When services are provided, the Medicaid fee-for-service reimbursement applies. In addition, PCPs will receive a monthly roster of enrolled members. It is required that incorrect member information is noted and a revised roster be returned to the HPES enrollment unit for updating. This information may be returned by fax to

(page 48)

802-878-3440, attn: enrollment or mailed to: HP Enterprise Services, attn: Enrollment, PO Box 888, Williston, VT 05495

Added**************************************************************************************


2.3.2

Emergency in-state inpatient hospital admissions do not require prior authorization. Members are required to notify their PCP of the emergency as soon as possible.

PRIOR AUTHORIZATION AND NOTIFICATION FOR HOSPITAL ADMISSIONS

Added**************************************************************************************


2.2.8

All individually participating or group identified PCPs must notify HP of their intention to withdraw from participation,

NOTICE OF TERMINATION OF PARTICIPATION IN PC PLUS

in writing, at least 90 days prior to the termination date. Providers are required to give their patients 30 days notice prior to termination.

Added: above red text to section

Deleted

**************************************************************************************

:: Closure of a practice due to the death of a PCP or sale of an individual practice, a group practice or a clinic, will automatically terminate participation in the PC Plus plan.

5/1/2011

http://www.vtmedicaid.com/�

mailto:[email protected]�


2.3.2

Select procedures and diagnostic tests require notification to the DVHA Clinical Unit. Notice for elective care should be given at least five days prior to the hospital admission. Services requiring prior authorization from the DVHA in the fee-for-service program will also require prior authorization in PC Plus Program. If prior authorization is required and obtained for an inpatient stay, no additional notification is required upon admission.

PRIOR AUTHORIZATION AND NOTIFICATION FOR HOSPITAL ADMISSIONS

Emergency in-state inpatient hospital admissions do not require prior authorization. Members are required to notify their PCP of the emergency as soon as possible.

All out-of-state urgent/emergency inpatient hospital admissions (excluding designated border hospitals, see UB-04 Supplement) require notification be made to the DVHA Clinical Unit within 24 hours or the next business day of the admission. See the UB-04 Provider Manual at https://vtmedicaid.com/Downloads/manuals.html for further information regarding out-of-state inpatient hospital admissions.

Added**************************************************************************************

: above red text to section.

(5/1/2011)

1.3.5 CO-PAYMENTS (page 35 & 36)

VHAP Primary Care Plus Beneficiaries

Vision Coverage: For beneficiaries with category codes VG, VD, VJ & VM.

-Aid Categories J3-J8, U1-U6 and UX:

Added**************************************************************************************



VHAP Managed Care

(page 64)

NO U1, U2, U3, U4, U5, U6, UX, J3, J4, J5, J6, J7, J8

Added**************************************************************************************


(4/1/2011) 1.4.9 FORMS AND MANUALS (page 46)

Deleted: Ambulance Certification Form

Added

**************************************************************************************

: Abuse & Team Care Referral Form, Vision Eligibility Verification Request Fax Form and Web Services Account E-mail Request Form

(3/1/2011)

1.2.22 TIMELY FILING (page 26) -Inpatient claim, the timely filing limit is 180 days from the date of discharge.

Added**************************************************************************************


https://vtmedicaid.com/Downloads/manuals.html�


(2/1/2011) 1.1.8 CLAIM SUBMISSION & CORRESPONDECE MAILING ADDRESSES (page 16) To ensure your request is processed in a timely manner, please use the correct PO Box specific to each type of correspondence mailed to HP Enterprise Services.

PO Box 999 – UB04 Claim Forms

PO Box 777 – CMS 1500 Forms

PO Box 1710 – Dental and Vision Claim Forms

PO Box 1645 – All Checks

PO Box 888 – All Other Mail & Inquiries

Williston, VT 05495-0888

Added**************************************************************************************

: red section

1.2.22 TIMELY FILING (page 26) -A beneficiary’s eligibility was made retroactive and the date of service is within the retroactive period. The claim must be submitted within the first six months of the date on the Notice of Decision. Include a note with the claim stating the retroactive date of eligibility.

Replace**************************************************************************************

: six months with 12 months

1.4.9 FORMS AND MANUALS

Alternate Reporter Request

(page 49)

Added**************************************************************************************

: form to list

(1/1/2011) 1.2.15 GUIDELINES (page 24) 3. Outpatient Rehabilitative Care (OT, PT, ST)-extension of services for adult beneficiaries beyond the initial 30 combined visits per calendar year can be requested for the following diagnoses: spinal cord injury, traumatic brain injury, stroke, amputation, or severe burn.

Added: red text Deleted**************************************************************************************

: the initial first four months of care

1.2.22 TIMELY FILING

-A beneficiary’s eligibility was made retroactive and the date of service is within the retroactive period. The claim must be submitted within the first six months of the date on the Notice of Decision. Include a note with the claim stating the retroactive date of eligibility.

(page 26) For information on timely filing and adjustment requests see section 4.2.1 ADJUSTMENT REQUESTS & TIMLEY FILING.


Deleted: Attach a copy of the Notice of Decision.

Added**************************************************************************************

: above red text

1.3.6 NOTICE OF DECISION (page 36)

Deleted**************************************************************************************

: retroactive eligibility or

1.3.8 RETROACTIVE ELIGIBILITY (page 36) Vermont Medicaid eligibility is occasionally granted retroactively. The provider may bill for services rendered during the retroactive period. A note indicating the date of retroactive eligibility must accompany the claim to waive the timely filing limit. See section 1.2.22.

Deleted: A Notice of Decision letter (DVHA220)

Added**************************************************************************************

: red text

1.3.10 LOCK-IN STATUS

The same “lock-in” procedure is used to name the primary care provider for a PC Plus beneficiary. This “lock-in” reflects the beneficiary’s choice of primary care physician. This information is also available through the VRS and the Vermont Medicaid web site.

(page 36) The term “lock-in” is used to describe a beneficiary whose access to certain services is restricted to one or more designated providers. If a beneficiary is locked into a provider, that provider’s name(s) is available on the VRS and the Vermont Medicaid website. Claims for services to “lock-in” beneficiaries (Vermont Medicaid and Dr. Dynasaur) by any provider not named, are not reimbursable, except in the case of an emergency or when providers perform a service by referral from the named provider.

Deleted

1.3.10

: (above text) Section name change from Lock-in-Status to Team Care Program

TEAM CARE PROGRAM

The “lock-in” procedure also applies to a PC Plus beneficiary. The “lock-in” reflects the beneficiary’s choice of primary care physician. This information is also available through the VRS and the Vermont Medicaid web site.

(page 36)_ The Team Care Program restricts a beneficiary to one physician and one pharmacy. If a beneficiary is "locked-in" to a provider, that provider’s name is available on the VRS and the Vermont Medicaid website. Claims for services by any provider other than the "lock-in" provider(s) are not reimbursable by Vermont Medicaid, except in the case of an emergency or when a provider performs a service by referral of the named provider.

Added**************************************************************************************

: red text

(12/01/2010) 1.2.9 NATUROPATHIC PHYISICANS Please see NATUROPATHIC PHYSICIANS in the CMS 1500 Supplement.

Deleted: section included Naturopathic Physicians under section 1.2.12 PAYMENT – DVHA PRIMARY **************************************************************************************

http://www.vtmedicaid.com/Downloads/manuals.html�


1.2.12 PAYMENT – DVHA PRIMARY (page 22) Naturopathic Physicians – Reimbursement basis is the lower of the provider’s charge or Vermont Medicaid rate on file.

Added:**************************************************************************************

red text

2.2.3 PROVIDER ENROLLMENT STATUS CHANGES (page 50) Group Composition

In addition, any provider who has not previously participated in the PC Plus plan will need to complete the Agreement for Participation located at

: If there is any change in the composition of individual providers in a group that originally agreed to participate in the Primary Care Plus Plan, the moving PCP is required to complete a new Agreement for Participation prior to the effective date of change. .

vtmedicaid.com/Downloads/forms.html.


Group Composition: If there is any change in the composition of individual providers in a group that originally agreed to participate in the plan, HP must be notified in writing at least 30 days prior to the effective date of change. In addition, any provider who has not previously participated in the PC Plus plan will need to complete an “Application for Participation”.

Deleted

(11/01/2010)

: above text **************************************************************************************

1.2.10 WHO IS RESPONSIBLE FOR PAYMENT

Federal Medicaid policy does not permit providers to bill Vermont Medicaid or the beneficiary any fee for missing a scheduled appointment.

(page 20)

Added:**************************************************************************************

red text at end of section

1.3.11 MEDICAID AND MEDICARE CROSSOVER BILLING

If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA, submit a CMS 1500 claim, completed to the DVHA specifications, along with the Medicare denial to HP within twelve months of the date of service.

(page 36)

Other Out-of-State Providers (Except New Hampshire

6. The Medicare payment date must appear on the Medicare Attachment Summary Form. If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the DVHA, submit a CMS 1500 claim, completed to the DVHA specifications, along with the summary form to HP within twelve months of the date of service. See 1.2.23 Timely Filing.

): All out-of-state providers should first bill their regional Medicare carrier for services to dual eligible Vermont residents. After Medicare payment is received, send a claim to HP for payment of any coinsurance or deductible as follows:

Changed**************************************************************************************

: six months to twelve months.

(10/01/2010) TABLE OF CONTENTS3.1

(page 2) POINT OF SALE (POS) ……………………………………………………………………………...56


3.1.1 POS DEVICE………………………………………………………………………………..56 3.1.2 INFORMATION AVAILABLE…………………………………………………………….56 3.1.3 INSTALLATION AND OPERATION……………………………………………………..57 3.1.4 FUNCTION KEYS………………………………………………………………………….57 3.1.5 ERROR MESSAGES………………………………………………………………………..58 3.1.6 ELIGIBILITY VERIFICATION…………………………………………………………....59 3.1.7 BENEFICIARY INELIGIBLE……………………………………………………………...59 3.1.8 MAINTENANCE FUNCTIONS……………………………………………………………60 3.1.9 SET DATE AND TIME……………………………………………………………………..60 3.1.10 PROVIDER KEY CHANGE………………………………………………………………61 3.1.11 SAMPLE POS TRANSACTIONS………………………………………………………...61

Deleted:

**************************************************************************************1.1.5

above sections from table of contents and deleted all references to the POS Device throughout this manual.

GLOSSARY OF TERMS AND PHRASES

GREEN MOUNTAIN CARE CARD- Each Beneficiary receives a Green Mountain Care member card. Beneficiaries generally get cards two-three weeks after being determined eligible, the notice of eligibility will confirm status in the first few weeks.

(page 10)

Added

PC PLUS CARD-A gold-colored identification card that can be used with the POS device to confirm the bearer’s eligibility. Each PC Plus member is required to have one. Beneficiaries generally get cards two-three weeks after being determined eligible, the notice of eligibility will confirm status in the first few weeks.

: above text

Deleted

LOCK-IN-An action that restricts a beneficiary’s choice of medical provider for a reasonable time because of over-utilization of certain services. Lock-in is also used to designate the beneficiary’s primary care physician when one is required. The locked in provider can be identified by using the automated eligibility verification systems: the HP Voice Response System (VRS), 802-878-7871, option 1; or the online Transaction Services at

: above text

http://www.vtmedicaid.com/Interactive/login2.html.

Deleted: beneficiary’s VermontAIM identification swipe card with the POS device, VRS, and through the website (www.vtmedicaid.com).

Added:

POINT-OF-SALE (POS) DEVICE)-A device by which enrolled providers can obtain beneficiary eligibility information by swiping an identification card.

above red text

Deleted

VERMONTAIM CARD-A green plastic identification card that can be used with the Eligibility Verification System to confirm the bearer’s eligibility.

: above text

Deleted**************************************************************************************

: above text

1.3 BENEFICIARY INFORMATION"Beneficiary" is the term used to refer to a person who has been determined eligible for and enrolled in one of the Vermont Medicaid programs. Eligibility is determined at a district office of the Vermont Department for Children and Families, including the Health Access Eligibility Unit in Waterbury, based on a review of the applicant's needs, income and resources. The various Vermont Medicaid programs have differing eligibility requirements and benefits.

(page 27)

http://www.vtmedicaid.com/Interactive/login2.html�


Each Beneficiary is assigned a unique identification number (UID) and receives a Green Mountain Care member card. The UID number will be 1 to 8 digits in length. Enter the UID number on your claim exactly as it is shown on the beneficiary's card.

Providers must verify the patient's eligibility and other insurance information using the patient's Medicaid UID number, by accessing either of the automated eligibility verification systems: the HP Voice Response System (VRS), 802-878-7871, option 1; or the online Transaction Services at http://www.vtmedicaid.com/Interactive/login2.html. In the event, a provider only has access to a member's Social Security Number, these systems will provide the UID number required for claim submission.

Added

“Beneficiary” is the term used to refer to a person who has been determined eligible for and enrolled in one of the Vermont Medicaid programs. Eligibility is determined at a district office of the Vermont Department for Children and Families, including the Health Access Eligibility Unit in Waterbury, based on a review of the applicant’s needs, income and resources. The various Vermont Medicaid programs have differing eligibility requirements and benefits. Providers are able to verify the patient’s eligibility, the patient’s ID number and other insurance information by swiping the identification card through the POS device or through use of the VRS or the

: red text

www.vtmedicaid.com website under Transaction Services.

October 1, 2010 is the start date for use of the unique identification number (UID) that must be used for each beneficiary. Use of the UID number allows removal of the Social Security number currently used for member cards and claim submission. This change will help protect our members' personal information. In September, all beneficiaries will receive their new health plan ID cards in the mail; however, do not begin billing with the new ID number until October 1. In order to facilitate this transition, our automated eligibility verification systems will allow you to check eligibility with either a Social Security number or the unique ID number. Use either the online Transaction Services (http://www.vtmedicaid.com/Interactive/login2.html) or the HP Voice Response System (Malcolm) 802-878-7871, option 1. If you only have access to a member's Social Security number, these automated systems will provide you with the unique ID number for your claim

Deleted**************************************************************************************

: above text

(09/01/2010

1.2.12

)

PAYMENT-DVHA PRIMARY (page 22) Independent Radiology-Reimbursement basis is the lower of the provider’s actual charge for the Vermont Medicaid rate on file not to exceed the Medicare maximum allowable amount. There is no cost settlement. For additional Radiology information, see the CMS 1500 Manual.

Added**************************************************************************************

: red text

1.3.12 THIRD PARTY LIABILITY (TPL) / OTHER INSURANCE (OI)OTHER INSURANCE ATTACHMENTS- Providers may submit electronically to HP claims that have been denied by another insurance company (third party payer/primary payer) when that payer has denied the claim using certain adjustment reason codes. Providers are required to include the adjustment reason code used by the primary payer when submitting the claim but will not need to send a copy of the primary insurance attachment. The list of adjustment reason codes that will be accepted electronically is available at www.vtmedicaid.com/Downloads/manuals , select 837 Adjustment Reason Codes. HP may select your claim

(page 39)





for post payment review and request a copy of the explanation of benefits; if so, providers are required to supply all supporting documentation in a timely manner. Failure to do so will result in the recoupment of your paid claim.

When submitting a paper claim, an attachment is needed only when a third party insurance carrier has not made a payment. Providers must attach documentation from the carrier that verifies the beneficiary’s name, insurer’s name, dates of service, the amount reimbursed and the payment or denial date. If the carrier does not include this information in the documentation (i.e. the carrier issues a blanket statement that the particular service is not covered), the provider must write the necessary information on the attachment, then sign and date the attachment. It must be clear that the attachment relates to the specific services billed on the Medicaid claim.

Added**************************************************************************************

: above red text

(07/26/2010Replaced: The Office of Vermont Health Access (OVHA) with the Department of Vermont Health Access (DVHA), throughout manual.

)

**************************************************************************************

1.3.12 THIRD PARTY LIABILITY (OTHER INSURANCE)

Providers are required to apply all third party payment resources prior to billing Vermont Medicaid. Third party resources include but are not limited to, Medicare, private/group health insurance plans, accident insurance, military and veteran’s benefits and worker’s compensation.

(page 38)

TPL VERIFICATION-The beneficiary’s other insurance information, including the name of the other insurance company, address, carrier code and type of coverage will be furnished by the POS device, the Vermont Medicaid website or , and VRS when the provider checks the beneficiary’s eligibility. Providers should review the beneficiary’s eligibility information for the date of service and must bill other insurance carrier(s) before billing Vermont Medicaid.

OTHER INSURANCE DENIALS- 1. When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim as “non-covered” or “benefits exhausted”, the provider does not

· If the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request authorization from the DVHA in the regular manner (fax all standard documentation required for a clinical review) and include a copy of the other insurer’s or Medicare’s denial.

need to appeal to that primary insurer before billing Medicaid.

· If the code/service does NOT require prior authorization from Vermont Medicaid, then the provider can bill Medicaid directly with a copy of the primary insurer’s denial attached.

2. When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim for other reasons (such as “not medically necessary”, “pre-existing condition” or “waiting period not met”), the provider must first appeal to the primary insurer. Only after all OI/Medicare appeals (through the Qualified Independent Contractor level and BISHCA if eligible and available) are denied can the provider then request coverage by Vermont Medicaid. All documentation showing the original and appeals’ denials must be attached.

· If the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request retroactive authorization from the DVHA in the regular


manner (fax all standard documentation required for a clinical review) and include copies of the other insurer’s or Medicare’s denials and appeals.

· If the code/service does NOT require prior authorization from Vermont Medicaid, then the provider can bill Medicaid directly with copies of the primary insurer’s denials (original and appeals) attached.

3. For beneficiaries covered by Medicare, the requirement to go through the Medicare Qualified Independent Contractor appeal level applies with the exception of wheelchairs that Medicare denies or downgrades. Upon documentation of the Medicare action, Medicaid will make its own medical necessity and payment determination.

4. The DVHA will reject a request if there is reason to believe that the OI received incorrect or incomplete information on which to base its decision.

5. It is highly recommended that providers determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by both OI or Medicare and the DVHA.

In order for providers to determine whose rules will apply, it is imperative that providers understand how to find and interpret the information available. Providers can access this information via the Vermont Medicaid website (www.vtmedicaid.com) or the Voice Response System (VRS). Please see VOICE RESPONSE SYSTEM for further information

Deleted: above text

1.3.12

Vermont Medicaid is the payer of last resort. Providers are required to pursue and apply all third party payment resources prior to billing Vermont Medicaid. Third party resources include, but are not limited to, Medicare, private/group health insurance plans, accident insurance, military and veteran’s benefits and worker’s compensation.

THIRD PARTY LIABILITY (TPL) / OTHER INSURANCE (OI)

TPL VERIFICATION- The beneficiary’s other insurance information, including the name of the other insurance company, address, carrier code and type of coverage, is available on the Vermont Medicaid website, Provider Web Services (www.vtmedicaid.com/secure/logon.do),

and the Voice Response System (VRS) when the provider checks the beneficiary’s eligibility. Providers will review the beneficiary’s eligibility information for the date of service and must bill other insurance carrier(s) before billing Vermont Medicaid. Use of the available information will guide providers in billing.

TIMELY FILING OF OI CLAIMS- Providers will respect the beneficiary’s right to receive all medically necessary services and equipment in a timely manner and must submit claims to primary insurers promptly to mitigate issues with beneficiary primary insurance benefits exhausting.

OTHER INSURANCE DENIAL / DVHA AUTHORIZATION REQUEST The following procedures are required for DVHA authorization requests when the primary insurer has reviewed and denied a claim request for an item or service:

OI Denial for Non-Covered or Benefits Exhausted- The provider is required to submit to the DVHA the authorization request form (Medical Necessity Form or other) with all standard documentation, the notice of denial from the primary insurer that indicates the item or service is not a covered benefit or that the benefit limit was determined to be exhausted, and all necessary documentation to support medical necessity. The DVHA will then review.

-The provider does not need to appeal to the primary insurer before billing Medicaid when the item/service is not covered or benefits are exhausted.


-If the code/service does not

OI Denial for Not Medically Necessary - The provider and/or beneficiary is required to pursue all levels of reconsideration and appeals with the primary insurer. If the request remains denied by the primary insurer, the provider and/or beneficiary is required to seek review by the BISHCA if the cost of the item or service exceeds $100. If the denial stands, then the provider may submit the request to the DVHA with copies of all of the original documentation, the denials from the primary insurer and the BISHCA’s support of the denial. The provider should not submit any additional documentation than what was reviewed by the primary insurer.

require authorization from Vermont Medicaid, then the provider can bill Medicaid directly with a copy of the primary insurer’s denial attached.

-If the code/service does not

Medicare Qualified Independent Contractor - For beneficiaries covered by Medicare, the requirement to go through the Medicare Qualified Independent Contractor appeal level applies, with the exception of wheelchairs that Medicare denies or downgrades. Upon documentation of the Medicare action, Medicaid will review for medical necessity and payment determination.

require authorization from Vermont Medicaid, then the provider can bill Medicaid directly, with copies of the primary insurer’s denials (original and appeals) and the BISHCA’s support of the denial attached.

The DVHA will reject a request if there is reason to believe that the OI received incorrect or incomplete information from the provider and based its decision on that incorrect or incomplete information. Providers must determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by both OI or Medicare and the DVHA.

************************************************************************************** Added: above text

1.3.13 WORKERS COMPENSATION/ACCIDENT LIABILITY BILLING (page 40) When a provider bills worker’s compensation and the claim is denied the provider then has 1 year from the date of service to submit their claim to Vermont Medicaid for payment.

**************************************************************************************

Added: red text

(06/08/2010) 1.2.4 ENROLLMENT AND CERTIFICATION

To assure that provider enrollment is uninterrupted, all requested applicable documentation is required to be returned to HP by the date indicated on the recertification request letter.

(page 19) A provider must be re-certified in order to continue participation in the program. Approximately 60 days prior to the re-certification date, a recertification request letter will be sent to the provider’s address on file. The recertification letter will include the information and directions necessary to complete the recertification process. Providers are required to forward a copy of their current provider license, recertification request letter and in some cases the Provider Enrollment/Recertification Form, at time of notification. Providers providing laboratory services, must also include a copy of their current CLIA certification. A complete list of Provider Enrollment Forms can be accessed at http://www.vtmedicaid.com/Downloads/forms.html.

If a new provider’s license end date is within 6 months of the enrollment date, the provider will not be required to complete a recertification form for the short enrollment period. HP will print or request a new license and update the certification status – carrying the provider to the next cycle date to recertify.


Pre-printed provider recertification forms are mailed approximately one month prior to when current state licenses expire. HP should not receive provider recertification forms until the provider is able to attach their


new license, otherwise the forms will be returned. Please verify the information provided on the recertification form is valid and make any corrections as needed in red ink.

As a reminder, The Department of Vermont Health Access does not extend providers, nor do they retro-enroll providers. Please contact HP Provider Enrollment for questions or concerns.

**************************************************************************************

Deleted: above text

1.2.10 WHO IS RESPONSIBLE FOR PAYMENT

(page 21) Under the Provider Agreement (Conditions of Participation #9), failure to give advance notice that a Vermont Medicaid payment will not be accepted prevents the provider from billing the beneficiary. If the beneficiary is eligible for Vermont Medicaid and the provider has made the decision not to bill Vermont Medicaid for the service or item requested, the beneficiary must be informed in advance of providing the service.

To document that proper notice was given, providers are required to document the notice on their letterhead, have it signed by the beneficiary or the beneficiary’s parent/guardian, provide a copy to the beneficiary, and retain a copy in the beneficiary’s file. Failure to give advance notice prevents the provider from billing the beneficiary. When a beneficiary is billed, the claim cannot be submitted to HP Enterprise Services for processing.

If the beneficiary is eligible for Vermont Medicaid and the provider does not want to accept Vermont Medicaid payment for the service or item requested, the beneficiary must be informed in advance of providing the service. Appropriate documents, prepared by the provider, should be completed and signed by the beneficiary or parent to document that proper notice was given to the patient and the responsible adult has accepted the financial responsibility. The claim should not be submitted to HP for payment.


**************************************************************************************1.4.4

Deleted: above text

LOCUM TENENS

If a Locum Tenens physician is covering for a physician on leave, they are then allowed to use that physician’s NPI number for up to 60 days. Modifier Q6 (Service rendered by a Locum Tenens physician) should be used to show that the service was provided by a Locum Tenens physician.

(page 48) A Locum Tenens is a physician, usually hired from out of state, to “step in” for another provider that is on leave or has permanently left a practice. The Locum Tenens physician must have a license to practice in Vermont.

If a Locum Tenens physician is covering for a physician who has permanently left a practice, then the Locum Tenens physician must enroll with Vermont Medicaid.

**************************************************************************************

Replaced the word provider with physician

(05/14/2010) 1.4.1 INQUIRIES (page 45) The Provider Services Unit responds to telephone inquiries and email from 8:00a.m. to 5:00p.m., Monday through Friday, except on State assigned holidays.

**************************************************************************************

Deleted: and email


1.4.3 GUIDELINES FOR BILLING INCIDENT TO

Also, with the exception of our “on-site” requirements, it is our intention to follow Medicare guidelines.

(page 47) Note: These guidelines do not apply when the provider has a separate agreement with the DVHA on billing practices.

When a provider bills for a physician’s assistant using an AM modifier, the provider will be reimbursed at 90% of the allowed amount and is not considered “incident-to”. Therefore, the Medicare “incident-to” rules do not apply.

**************************************************************************************

Deleted: red test

(05/05/2010) 1.1.4 DIRECTORY OF OFFICESAdded: (800) 479-6151

(page 7)

Deleted: Tel: (802) 241-3978 **************************************************************************************

1.1.3 MANUAL AND RULE ACCESSIBILITY (page 7) The most recent published version of this Provider Manual is located at www.vtmedicaid.com/Downloads/manuals.html. The following manual supplements are also viewable: Prior Authorization, CMS 1500 and UB 04.

The Pharmacy Benefit Management Program Provider Manual is located at ovha.vermont.gov/for-providers under the Pharmacy section. The Pharmacy Benefit Management Program is for prescription drugs dispensed by retail pharmacies.

Medicaid Rule, and rules for the programs encompassed under “Medicaid”, is located online at humanservices.vermont.gov/on-line-rules/ovha.

************************************************************************************** Added: red text

1.1.12 MEDICAL NECESSITY FORM (MNF)The OVHA MNFs are Form OVHA 286 and OVHA 60. An Eyeglass Medical Necessity Form is available (April 2010). Other medical necessity forms are acceptable as long as the following information is provided:

(page 17)

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1.2.1.1 PHARMACY TAX ASSESSMENT FORM

A monthly assessment is due to the State of Vermont for each prescription fill or refill sold by retail pharmacies. This applies to all scripts, and not only to Vermont Medicaid scripts. The amount of the assessment is $0.10 for each prescription fill or refill. The completed Pharmacy Assessment Monthly Documentation Form, available online at:

(page 18)

http://ovha.vermont.gov/for-providers/pharmacy-forms along with additional information regarding the tax, needs to accompany each monthly payment. Chain pharmacies with more than one NPI number should complete a separate form for each facility every month.

**************************************************************************************

Added section

1.2.5 PAYMENT CONDITIONS (page 20)

http://ovha.vermont.gov/for-providers�

http://ovha.vermont.gov/for-providers/pharmacy-forms�


Added

**************************************************************************************1.2.25

: - Billing may not be done in advance of any service to be performed or supplied.

CLIA CERTIFICATION (Page 27) Providers who perform laboratory services and who do not have CLIA certification, should contact the Vermont Department of Health, 108 Cherry Street, Burlington, VT 05401 by phone at (802) 652-4145 or by fax at (802) 865-7701 for information.

Removed: Vermont Department of Disabilities, Aging and Independent Living, Division of Licensing and Protection (802) 241-2345

Added: red text

**************************************************************************************

1.3 BENEFICIARY INFORMATION

October 1, 2010 is the start date for use of the unique identification number (UID) that must be used for each beneficiary. Use of the UID number allows removal of the Social Security number currently used for member cards and claim submission. This change will help protect our members' personal information. In September, all beneficiaries will receive their new health plan ID cards in the mail; however, do not begin billing with the new ID number until October 1. In order to facilitate this transition, our automated eligibility verification systems will allow you to check eligibility with either a Social Security number or the unique ID number. Use either the online Transaction Services (

(Page 27)

http://www.vtmedicaid.com/Interactive/login2.html) or the HP Voice Response System (Malcolm) 802-878-7871, option 1. If you only have access to a member's Social Security number, these automated systems will provide you with the unique ID number for your claim

************************************************************************************** 1.3.11

Added: red text

MEDICAID AND MEDICARE CROSSOVER BILLING (Page 37)

Changed: 6 weeks to 30 days

Changed: EOMB to **************************************************************************************

summary form


Psychiatric Inpatient Supplement

Manuals - www.vtmedicaid.com/Downloads/manuals.html

Admission Notification (Out-of-State Hospital Psychiatric Inpatient Services) CMS 1500 Medicare Attachment Summary Form Dental Prior Authorization Forms Eyeglass Prior Authorization Form Medicaid Fraud Waste & Abuse Referral Form Medical Necessity Provider Enrollment Forms: (Electronic Funds & Funds Change, Change of Address, Group Affiliation, PCPlus, & Termination Notice) Transportation UB 04 Medicare Attachment Summary Form

Forms – www.vtmedicaid.com/Downloads/forms.html

**************************************************************************************



3.4 2009 AID CATEGORY LISTING

· Children with Special Health Needs (CSHN) for PT, OT, ST, NU & AU services only. (Aid Category SH)

(page 74 & 75) Added 2 additional programs:

· Family Infant Toddler Program (FITP) for PT, OT, ST, NU & AU services only. (Aid Category FI) **************************************************************************************

(01/08/2010) 3.4 2009 AID CATEGORY LISTING (page 74)

**************************************************************************************


1.1.3 MANUAL AND RULE ACCESSIBILITY (new section Page 7) The most recent published version of this Provider Manual is located at http://www.vtmedicaid.com/Downloads/manuals.html. The following manual supplements are also viewable: Prior Authorization, CMS 1500 and UB 04.

Added to section 1.1

1.1.4 DIRECTORY OF OFFICES (page 7)

Deleted: DCF maintains local district offices to process all other eligibility applications. The district offices to process all other eligibility applications. The district offices and towns under their jurisdiction are as follows.

Deleted: District office telephone numbers.

Added:

Call Center/IVR system

A call center/interactive voice response (IVR) system services providers and beneficiaries statewide. Providers should stay on the line after the message for a separate queue and will be serviced directly.

Tel: 800-479-6151 **************************************************************************************

1.2.20 SANCTIONS (page 25) The OVHA may take administrative action against providers found in violation of Vermont Medicaid policy. See section M155/7106 of the Medicaid Rules for regulatory details pertaining to sanctions and appeals. A copy of Medicaid Rules is posted at http://humanservices.vermont.gov/on-line-rules, and at each DCF District Office and at the state library in Montpelier.

Deleted: kept at DCF District Office and at the state library.

Added: posted at http://humanservices.vermont.gov/on-line-rules, and at each DCF District Office and at the state library in Montpelier. **************************************************************************************

(09/04/2009)

1.3.16 BENEFICIARY BILL OF RIGHTS

As a member of a Vermont health care program, a beneficiary has the right to:

(Page 43) As a Managed Care Organization (MCO), the OVHA must ensure that its enrolled health care providers are aware of our Beneficiary Bill of Rights and that health care providers take these rights into account when providing services to beneficiaries. The Vermont Health Care Programs: Beneficiary Bill of Rights (March 2009) is as follows:

-Be treated with respect and courtesy -Be treated with thoughtfulness for his or her dignity and privacy -Choose and change providers -Get facts about program services and providers -Get complete, current information about his or her health in understandable terms -Be involved in decisions about his or her health care, including having questions answered and having the right to refuse treatment


http://humanservices.vermont.gov/on-line-rules�

http://humanservices.vermont.gov/on-line-rules�


-Ask for and get a copy of his or her medical records and ask for changes to be made to them when he or she believes the information is wrong -Get a second opinion from a qualified provider who is enrolled in Vermont Medicaid -Complain about the program or his or her health care -Be free from any form of restraint or isolation used as a means of bullying, discipline, convenience, or retaliation -Ask for an appeal if services are denied that he or she thinks are needed. **************************************************************************************

(09/04/2009)

1.2.26 CLINICAL PRACTICE GUIDELINES (Page 27) The Department of Vermont Health Access has adopted various Clinical Practice Guidelines that are based upon evidence based medicine. These guidelines outline the preferred approach for most patients and are used to support the decision making processes. The guidelines can be found at http://ovha.vermont.gov/for-providers under Clinical Initiatives. **************************************************************************************

(08/25/2009)

OTHER INSURANCE DENIALS (Page 37)

1.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim as “non-covered” or “benefits exhausted”, the provider does not

a.) If the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request authorization from the OVHA in the regular manner (fax all standard documentation required for a clinical review) and include a copy of the other insurer’s (or Medicare’s) denial.

need to appeal to that primary insurer before billing Medicaid.

b.) If the code/service does NOT require prior authorization from Vermont Medicaid, then the provider can bill Medicaid directly with a copy of the primary insurer’s denial attached.

2.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim for other reasons (such as “not medically necessary”, “pre-existing condition” or “waiting period not met”), the provider must first appeal to the primary insurer. Only after all OI/Medicare appeals (through the Qualified Independent Contractor level and BISHCA if eligible and available) are denied can the provider then request coverage by Vermont Medicaid. All documentation showing the original and appeals’ denials must be attached.

a.) If the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request retroactive authorization from the OVHA in the regular manner (fax all standard documentation required for a clinical review) and include copies of the other insurer’s or Medicare’s denials and appeals.

b.) If the code/service does NOT require prior authorization from Vermont Medicaid, then the provider can bill Medicaid directly with copies of the primary insurer’s denials (original and appeals) attached.

3.) For beneficiaries covered by Medicare, the requirement to go through the Medicare Qualified Independent Contractor appeal level applies with the exception of wheelchairs that Medicare denies or downgrades. Upon documentation of the Medicare action, Medicaid will make its own medical necessity and payment determination.

4.) The OVHA will reject a request if there is reason to believe that the OI received incorrect or incomplete information on which to base its decision.

5.) It is highly recommended that providers determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by both OI or Medicare and the OVHA.

In order for providers to determine whose rules will apply, it is imperative that providers understand how to find and interpret the information available. Providers can access this information via the Vermont Medicaid website




(www.vtmedicaid.com) or the Voice Response System (VRS). Please see VOICE RESPONSE SYSTEM for further information

**************************************************************************************

(06/30/2009)

SECTION 1-POLICY AND INFORMATION

Introduction

(Page 6)

Green Mountain Care, herein described as Medicaid, encompasses many programs including Dr. Dynasaur, Traditional Medicaid, VHAP, VHAP Managed Care, Medicaid Managed Care, VHAP-Pharmacy, VScript, VPharm, Premium Assistance, and Employee Sponsored Insurance. All of these programs are financed by a combination of both federal and state dollars. The Vermont General Assembly appropriates the state funds. The proportion of federal matching funds is determined for each state agency that delegates responsibility for the administration of the program to The Department of Vermont Health Access (OVHA). Other departments involved in program administration are as follows:

-Department of Aging and Independent Living (DAIL) -Department of Health, including The Department of Alcohol and Drug Abuse Programs -Department of Mental Health -Department of Education -Department for Children and Families

Deleted

**************************************************************************************

: The Vermont Medical Assistance Program ……Drug Abuse Programs and Mental Health Services…

1.1.3 DIRECTORY OF OFFICES

(Page 7)

BARRE 255 N. Main Street, Ste 5 05641-4160 Tel: 479-1041, 800-499-0113

Deleted

: Ste. 7 05641-4189 479-4260

BENNINGTON 150 Veterans Mem. Dr., Ste 6 05201-1918 Tel: 442-8541, 800-775-0527

Deleted

**************************************************************************************

: 200 Veterans Mem. Dr., Ste. 14 05201-1956 442-8138

1.1.4 GLOSSARY OF TERMS AND PHRASES

(Page 10) CROSSOVER CLAIM-A claim created by Medicare and sent to Medicaid for payment of deductible and co-payment amounts. This occurs when the Medicare beneficiary is also covered by Vermont Medicaid or is a Qualified Medicare Beneficiary (QMB) and the Medicare claim so indicates.

1.1.6 IMPORTANT ADDRESSES AND TELEPHONE NUMBERS (Page 15) Maximus 101 Cherry Street, Ste. 320 Burlington, Vermont 05402


Tel: (800) 250-8427 Fax: (802) 651-1528 TTY: 888-834-7898

Deleted

Department of Disabilities, Aging & Independent Living Waterbury, Vermont 05671-1201 Tel: (802) 241-2880 Fax: (802) 241-2897

:5 Burlington Square, Floor 5

Deleted

**************************************************************************************

: Department of Developmental & Mental Health Services

1.2.4 ENROLLMENT AND CERTIFICATION

If a new provider’s license end date is within 6 months of the enrollment date, the provider will not be required to complete a recertification form for the short enrollment period. EDS will print or request a new license and update the certification status – carrying the provider to the next cycle date to recertify.

(Page 19) … Retroactive enrollment will be allowed to cover urgent or emergent care delivered by a provider outside of Vermont that is not considered a border provider.

Court ordered providers would only be enrolled for dates consistent with the order/decision. A provider must be re-certified in order to continue participation in the program. Approximately one month prior to the re-certification date, a new provider agreement will be sent to the provider’s address on file. The new provider agreement must be completed, signed and dated by the provider, and returned to EDS with a copy of the current license or certification documents. To assure that provider enrollment is uninterrupted, the form should be sent to EDS by the return date indicated.

Enrollment will be rejected if: -Mandatory information is not received -The provider is disbarred or sanctioned from participation in federal programs -The provider is disbarred or sanctioned by the State of Vermont

Pre-printed provider recertification forms are mailed approximately one month prior to when current state licenses expire. EDS should not receive provider recertification forms until the provider is able to attach their new license, otherwise the forms will be returned. Please verify the information provided on the recertification form is valid and make any corrections as needed in red ink. As a reminder, The Department of Vermont Health Access does not extend providers, nor do they retro-enroll providers. Please contact EDS Provider Enrollment for questions or concerns. CLIA

**************************************************************************************

: Providers that provide any laboratory services, must include a current copy of the CLIA certification with the provider recertification form.

1.2.18 SUPPLEMENTATION

**************************************************************************************

(Page 25) …3. Specific allowed supplementations authorized in Medicaid Rule 910.2/7601.2.

1.2.24 TIMELY FILING (Page 27) …The OVHA will consider paying an untimely claim in unusual circumstances. A request for an exception can be made by sending the claim and a detailed explanation of why an exception should be granted to: EDS, P.O. Box 888, Williston, Vermont 05495-0888 Attn: Timely Filing Appeals.

Deleted

**************************************************************************************

: The Department of Vermont Health Access, 312 Hurricane Lane, Suite 201, Williston, Vermont 05495

1.3.2 HEALTH CARE BENEFIT PROGRAMS (Page 28-29)


VHAP-Limited VHAP Limited is a transition program used prior to enrollment in managed care, PC Plus. As soon as beneficiaries are determined eligible and pay any required premium, they are covered for certain services on a fee-for-service basis. VHAP Limited beneficiaries are issued a VermontAIM identification care. Premiums are required.

Deleted: Co-payments, see Section 1.3.4

VPharm The new Medicare Part D prescription drug benefit began on January 1, 2006. The pharmacy program called VPharm was created by The Department of Vermont Health Access to serve beneficiaries who qualify for state pharmacy benefits and are eligible for Medicare Part D. In general, VPharm covers drug classes that are excluded from the Part D benefit, and may assist with premiums and cost-sharing.

Healthy Vermonters Is for Vermonter’s who don’t have insurance for prescriptions, or for those whose commercial insurance plan has an annual maximum prescription benefit.

Deleted: Beneficiaries with drug coverage available through Medicare, will have their VHAP, VScript, and VScript expanded coverage converted to VPharm as of January 1, 2006. VPharm eligible beneficiaries have already been auto-enrolled in Part D prescription drug plans and notified. Qualified Medicare Beneficiary …A QMB is not issued a VermontAIM identification card and cannot be identified using Electronic Verification System (EVS).

Deleted

**************************************************************************************

: The beneficiary must present a Qualified Medicare Beneficiary Identification form (OVHA 289A) to be eligible for benefits.

1.3.3 ADVANCE DIRECTIVES (Page 29) Hospitals, nursing homes, home health agencies, hospices and prepaid health care organizations are required to provide certain patients with information about their right to formulate advance directives and maintain written policies and procedures with respect to advance directives. They are also required to document in patients’ files whether or not an advance directive is in effect, provide education for staff and the community on issues concerning advance directives, and ensure compliance with State law on advanced directives at their facilities. Providers are responsible to guard the confidentiality of beneficiary information in a matter consistent with the confidentiality requirements in 45 CFR parts 160 and 164 and as required by state law. http://www.cms.hhs.gov/securitystandard/downloads/securityfinalrule.pdf.

**************************************************************************************

1.3.4 CO-PAYMENTS (Page 34)

VHAP Pharmacy Beneficiaries

Effective 07/15/2009: Copays for prescriptions $29.99 or less = $1.00

-Aid Categories V1, V2, V3, V5 & V6:

Prescriptions $30.00 or more = $2.00

Deleted: 01/01/04 Zero co-pay for covered medications.

VScript Beneficiaries


-Aid Categories VA, VS, V7 & V8:


Deleted: 01/01/04: Co-pays eliminated.

VScript Expanded Beneficiaries


-Aid Categories VB, VC, VT & VU:


Deleted: 01/01/04: Co-pays eliminated.

VHAP Pharmacy with Medicare


-Aid Category V4:

http://www.cms.hhs.gov/securitystandard/downloads/securityfinalrule.pdf�



Deleted: 01/01/04 Zero co-pay for covered medications.

VPharm Pharmacy


-Aid Categories VD, VF, VG, VH, VI, VK, VL, VM, VN & VO:


Deleted

VPharm covers drug classes that are excluded from the Part D benefit. Vision Coverage: For beneficiaries with category codes VD, VG, VJ & VM.

: 01/01/04 Zero co-pay for covered medications.

**************************************************************************************

1.3.8 SPEND-DOWN (Page 35) In some cases, eligibility is contingent upon the applicant having extraordinary expenses. In these cases, the applicant must first become responsible for a specific dollar amount for medical expenses during a six-month period. The actual amount is known as the “spend-down” amount as calculated by DCF. A spend-down beneficiary becomes eligible for Vermont Medicaid on the day of the month in which the incurred medical expense amount equals or exceeds the specified “spend-down” amount. When the beneficiary becomes eligible, all providers performing a service on that first day of eligibility will receive a Notice of Decision letter (ESD 220MP) from the district office. The letter explains that the spend-down amount has been met by the beneficiary, or that a portion of the provider’s bill remains the responsibility of the beneficiary. The provider must deduct the spend-down amount, if any, shown in the ESD 220MP prior to claim submission.

Deleted

**************************************************************************************

: OVHA 220MP

1.3.10 MEDICAID AND MEDICARE CROSSOVER BILLING (Page 36)

Vermont and New Hampshire Providers: In order to crossover, Vermont Medicaid eligibility information must be clearly indicated on the Medicare claim. These claims will crossover automatically to EDS for payment. If you do not receive the OVHA payment within six weeks of the Medicare paid date, submit the claim to EDS with the Medicare Attachment Summary Form.

Deleted

These items need to match on both the claims and the EOMB…

: submit the claim to EDS as follows:

1. Dates of services 2. Beneficiary name 3. Procedure/Revenue Code 4. Billed amount 5. Attending physician NPI

*************************************************************************************

Other Out-of-State Providers (Except New Hampshire):

1. Send a claim completed to the OVHA specifications with a copy of the Medicare Attachment Summary Form attached.

All out-of-state providers should first bill their regional Medicare carrier for services to dual eligible Vermont residents. After Medicare payment is received, send a claim to EDS for payment of any coinsurance or deductible as follows:

2. If a copy of the Medicare claim is not available, you may complete a CMS 1500 claim form and attach a copy of the Medicare Attachment Summary Form, or attach documentation that Medicare does not cover the service.

3. The Medicare payment date must appear on the Medicare Attachment Summary Form.


If a service or item is denied by Medicare as non-reimbursable and is reimbursable by the OVHA, submit a CMS 1500 claim, completed to the OVHA specifications, along with the Medicare Attachment Summary Form to EDS within six months of the date of service.

Deleted

**************************************************************************************

: EOMB/Medicare payment sheet

1.4.3 GUIDELINES FOR BILLING INCIDENT-TO

Also, with the exception of our “on-site” requirements, it is our intention to follow Medicare guidelines. When a provider bills for a physician’s assistant using an AM modifier, the provider will be reimbursed at 90% of the allowed amount and is not considered “incident-to”. Therefore, the Medicare “incident-to” rules do not apply **************************************************************************************

(Page 45) Note: These guidelines do not apply when the provider has a separate agreement with the OVHA on billing practices.

SECTION 2-VERMONT HEALTH ACCESS PLAN – PC PLUS (Page 48) The Department of Vermont Health Access (OVHA) is responsible for administration of the Vermont Medicaid program.

Deleted

The OVHA is also responsible for implementing the Vermont Health Access Plan (VHAP), Medicaid expansion authorized in 1995 by the Vermont General Assembly and supported by a Section 1115 Research and Demonstration Waiver approved by the federal government, and subsequently the Global Commitment 1115 Waiver.

: ,which is part of the Department for Children and Family Services (DCF)


*Please note: -Sections below containing text in red font are additions to current policy. Previous verbiage will be noted, when applicable). -Section

CMS-1500 SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/13/2012 – 6/5/2009

headings below in red font are new sections* ************************************************************************

9/01/2012

PSYCHIATRY/PSYCHOLOGY (page 40) Code Description Units 90801 Diagnosis & Evaluation 1 unit=1 visit (limit - 40 units per calendar year)

Added:

************************************************************************ above text to section

DRUGS REQUIRING PRIOR AUTHORIZATION (page 21)

Replaced:

******************************************************************************

Medmetrics with Catamaran

INJECTIONS (page 28)

Replaced:

******************************************************************************

Medmetrics with Catamaran

MIDWIFE SERVICES

5. The total payment for any combination of obstetrical CPT codes cannot exceed 50% of the total obstetrical care rate

(page 32)

9. Antepartum visits can only be billed as separate claims

Deleted:

******************************************************************************

above text from section

SPEND-DOWN (FORM DVHA 220MP

5. Enter the spend down amount on the Medicare Attachment Summary Form (MASF) for Medicare crossover claim type: Y.

) (page 44)

a. If no Other Insurance payment, check box for NO (1b) on MASF; the provider is to enter the spend down amount in the other insurance field on the MASF.

b. If there is an Other Insurance payment, check box for YES (1a) on MASF; the provider is to enter the total combined amount of the other insurance payment and the spend down in the other insurance field (1c) on the MASF.

Added

******************************************************************************


VISION CARE & EYEGLASSES

· Eyeglass cases can be billed only by Classic Optical as part of the sole-source contract.

(page 46)


Added

******************************************************************************


PRESCRIBING PROVIDER

Doctors of Medicine (M.D.s), Doctors of Osteopathy (D.O.s), Nurse Practitioners (NPs), Physician Assistants (PAs) and certain other licensed practitioners may write prescriptions for DME and medical supplies.

(page 54)

Added

******************************************************************************


RENTED & LOANED EQUIPMENT

When DME is loaned (provided without charge) or rented, as part of an equipment trial and the equipment is then approved for purchase:

(page 55)

The claim for the equipment is required to include the UE modifier when the equipment is to be retained by the beneficiary and was not new at the time of the loan or initial rental. Only if the equipment was new, or if the used equipment is being replaced by new equipment, should this modifier be omitted.

The provider is to document the DME serial number in the beneficiary’s record.

Added

******************************************************************************


8/06/2012

AUDIOLOGICAL SERVICES/HEARING AIDS (page 16)

Batteries: One package of 6 batteries is reimbursable per month Hearing aid batteries are limited to a maximum of six per 30 days per beneficiary, and 1 battery equals 1 unit. This limitation is per hearing aid per ear when there is a written prescription from the physician. Prior authorization is not required. A completed Medical Necessity Form (MNF) substantiating medical need for the hearing aid must be kept on file for auditing purposes.


Deleted:

******************************************************************************

strikethrough text

8/01/2012


Exception: Beneficiaries under the age of six are allowed one pair of eyeglasses every year without obtaining prior authorization. Clinical best-practice validates annual replacement for children under age 6 years due to physical growth.

(page 45)

Added

******************************************************************************


7/01/2012

EVALUATION & MANAGEMENT SERVICES

Evaluation and Management: (99--- codes) The following limits apply:

(page 23)


· Services included within payment for E&M service

· Office visits limited to 5 per calendar month per attending

· New patient visits limited to one per beneficiary/attending/3 years

· One office visit/day for same beneficiary and same attending provider Moved

************************************************************************

: the above red text from the VISION & EYEGLASSES section to EVALUATION & MANAGEMENT SERVICES section.


Effective July 1, 2012

(page 45)

Classic Optical Laboratories, Inc. P.O. Box 1341

Youngstown, Ohio 44501

Phone: 888-522-2020 www.classicoptical.com

Business Hours: 8:00 am-5:30 pm EST, Monday through Friday

Eligibility Eligibility verification is the responsibility of the provider and must be verified before an order is sent to Classic Optical. Providers may check eligibility through web access at www.vtmedicaid.com or call the Voice Response System (VRS) at (800) 925-1706 (in-state only) or (802) 878-7871.

Prior Authorization

The following circumstances require prior authorization:

(PA) Medical necessity for special frames or lenses outside of Vermont Medicaid’s sole-source contract requires that the prescribing optometrist or ophthalmologist seek prior authorization from DVHA. This applies for new lenses when Classic Optical determines that the beneficiary's current lenses cannot be incorporated safely and reasonably into the special frames.

· Frame has been outgrown and needs to be replaced within the benefit period

· Replacement for a change in Rx (must be at least +/- 0.50 D in at least one eye) within the benefit period

· Replacement of frames or lenses other than those that are broken or lost within benefit period

· Scratched lenses to the extent that visual acuity is compromised.

The following benefits require prior authorization

· V2025 (deluxe frames)

· V2744 (photochromic lens)

· V2745 (any other tint added to the lens)

· V2762 (polarized lens)

· V2199, 2299, 2399, 2799 (miscellaneous vision service)

http://www.classicoptical.com/�



The Prior Authorization Form is available from

· Classicoptical.com or phone 1-888-522-2020

· DVHA.vermont.gov/for-providers/forms-1

See EVALUATION & MANAGEMENT SERVICES for information on billing non-routine vision office visits.

Added: Billing direction specific to Classical Optical Billing Information (red text)

Deleted

************************************************************************

: all references & billing direction specific to Chadwick Optical, Inc.

6/01/2012

AUDIOLOGICAL SERVICES/HEARING AIDS

Audiology services are provided to beneficiaries of any age. Coverage of hearing aids is limited to one hearing aid per ear every three years for specified degree of hearing loss. Prior authorization is required for requests prior to the three year limit. VHAP and VHAP Limited exclude coverage for hearing aids or examinations for the prescription or fitting of hearing aids.

(page 15)

Added

************************************************************************


SMOKING CESSATION COUNSELING

Face-to-face smoking cessation counseling is covered for pregnant Vermont Medicaid beneficiaries. The maximum number of visits allowed per calendar year is 16. This coverage applies when furnished by (or under the direction of) a physician or by any other health care professional who is legally authorized to furnish such services under state law and licensure. “Qualified” Tobacco Cessation Counselors are also allowed (requires at least eight hours of training in tobacco cessation services from an accredited institute of higher education).

(page 42)

Providers must code each claim with the correct diagnosis for tobacco use complicating pregnancy.

Pharmacological Coverage See the most recent Clinical Criteria document at http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria for Smoking Cessation Therapy information, preferred drug list and PA requirements. Added

************************************************************************


VISION CARE (page 45)

Eyeglasses: Coverage for eyeglasses (frames and/or lenses) is limited to one pair of glasses every two years per beneficiary. Reimbursement for earlier replacement is limited to the following: eyeglasses (frames and/or lenses) have been lost or broken beyond repair and either of these reasons is indicated on the claim form in the Notes field. Replacement of the original prescription constitutes new glasses and the beginning of the two year limitation period. Other reasons such as prescription/diopter change, scratched lenses, frame size or other special need will require prior authorization from the DVHA Clinical Operations Unit. See: Prior Authorization below.

http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria�



Effective July 1, 2012, providers submitting claims for lost or broken eyeglasses (lenses & frames) are required to include the KX modifier.

************************************************************************

5/01/2012

OBSTETRICAL CARE (page 36)

The fetal Non-Stress Test: 1 unit will cover the non-stress test for both twin A and twin B when billed with modifier 22. Notes are not required when a twin diagnosis is indicated on the claim.

Added

************************************************************************ : above red text to section

PSYCHIATRY/PSYCHOLOGY (page 38)

Substance Abuse

Enrolled Providers: -ADAP facility/Substance Abuse Treatment facility -Certified Adolescent ADAP Counselor/Addiction Medicine

Psychotherapy claims where the primary diagnosis is substance abuse or dependence (including alcohol or other drugs, excluding tobacco), are paid through the Office of Alcohol and Drug Programs to participants in their provider network of contracted substance abuse programs.

Deleted: above text from section

At minimum, the documentation in a mental health/substance abuse health record will include the following core components

Mental Health and Substance Abuse Health Record Documentation Standards

1. Identifying Data · Name/unique ID, date of birth, other demographic information, as needed

2. Dates of Service · Documentation by the primary treatment provider of all dates and times clinical services were

provided 3. Comprehensive Clinical Assessment (e.g., biopsychosocial, medical history, etc.)

· Evidence that a Comprehensive Clinical Assessment has been completed, with documentation of a presenting problem and client level of care to support clinical necessity for placement, such as

o Outpatient o Intensive outpatient o Partial hospitalization o Inpatient/residential

· Evidence of ongoing reassessment, as needed 4. Treatment and Continued Care Planning

· Documentation of treatment plan, including the following o Prioritization of problems and needs o Evidence that goals and objectives are related to the assessment o Evidence that goals and objectives are individualized, specific, and measurable, with

realistic timeframes for achievement o Specific follow-up planning, including but not limited to anticipated response to

treatment, additional or alternative treatment interventions, and coordination with other treatment providers (e.g., PCP)


5. Progress Notes · Documentation supporting continued need for services based on clinical necessity, including the

following o Dated progress notes that link to initial treatment plan o Updates or modifications to treatment plan o Interventions provided and client’s response o Printed staff name and signature or electronic equivalent.

For additional information concerning DVHA’s Mental Health and Substance Abuse Health Record Documentation Standards and resources, see http://dvha.vermont.gov/for-providers.

CPT Code 90801 can be used beyond the initial evaluation under limited conditions such as - Transitioning to a new therapist or mental health provider - Returning for therapy after an extended period of absence - New symptoms presenting unrelated to the original condition or a new focus in therapy

related to a crisis situation such as a major life change or worsening of conditions For additional information, go to http://dvha.vermont.gov/for-providers Mental Health & Substance Abuse.

90804 Psychotherapy-Less Than One Hour 1 unit=20-30 min.

90806 Psychotherapy 1 unit=45-50 min.

90808 Psychotherapy-More Than One Hour 1 unit=75-80 min.

CPT Code 90808 can be used under limited conditions such as - Temporary need for extended sessions as the patient transitions to less

frequent therapy sessions - Geographic or transportation issues that limit access to services - Immediate aftermath of an acute trauma or life event and need for emotional

stabilization and exploration of the incident - An unexpected crisis situation during or arising from a regularly scheduled

session (such as threats of violence or suicide) requiring time to stabilize the patient, involving family members or arranging for emergency care

- Therapeutic procedures requiring sessions of greater duration such as Prolonged Exposure Therapy (used by the Veteran’s Administration) for treating trauma related conditions.

DVHA follows the Medicare Local Coverage Determination guidelines which state “the use of psychotherapy services in excess of 60 minutes is not the standard of care in most jurisdictions. To support Medical necessity, the provider must document the patient’s need for these extended time codes”. Use of CPT 90808 must be substantiated by clinical documentation. For additional information, go to http://dvha.vermont.gov/for-providers Mental Health & Substance Abuse.


http://dvha.vermont.gov/for-providers�




************************************************************************ SPEECH AUGMENTATION DEVICES

Effective 6/01/2012, the Department of Vermont Health Access (DVHA) will begin covering ipad/ipod devices as dedicated speech generating/augmentative communication devices for VT Medicaid beneficiaries whose severe communication impairment prevents writing, telephone use, and/or talking. DVHA does not cover this or any other device to be used solely for educational, vocational, or avocational purposes. Multiple devices are not covered.

(page 55)

Because the device supplier is not a standard Durable Medical Equipment (DME) provider, Speech Language Pathologist (SLP) performing the evaluation will be considered the provider of record. The prescribing SLP is required to be an enrolled Vermont provider. If the beneficiary has more than one SLP, for example a school and a medical model SLP or an expert consultant, and one SLP is an enrolled VT Medicaid provider, SLP collaboration will be allowed during the evaluation/ prescribing process; the enrolled SLP submits the request.

Note: There has been no change to Medicaid Rule and no change to the prior authorization process for all other types of augmentative communication devices. Prior authorization is required for all augmentative communication devices.

A packet that includes the DVHA evaluation and prescription form, the DVHA Ownership form, Rule related to speech generating devices and a procedure checklist is available at: www.dvha.vermont.gov/for-providers/clinical-coverage-guidelines. See the link titled Augmentative Communication Device Packet.

Added

************************************************************************ : above red section to manual

4/01/2012

AUDIOLOGICAL SERVICES/HEARING AIDS

VHAP and VHAP Limited exclude coverage for hearing aids or examinations for the prescription or fitting of hearing aids.

(page 15)

Added


EVALUATION & MANAGEMENT SERVICES

When reporting with a surgical procedure with a 90 day, 30 day or a 10 day global period any E&M service billed during the global period by the same provider will be included within the surgical procedure payment and not reimbursed separately. Payments for surgical procedures with a 0 day global period will include established patient E&M services.

(Post Operative Care) (page 23)

Added

************************************************************************ : Section

OBSETRICAL CARE

A beneficiary may see more than one attending provider when billing multiple antepartum visits/services (CPT 59425 or CPT 59426) within the same billing group/practice. It is up to the practice to determine which attending provider number to use when submitting the claim.

(page 35)


http://www.dvha.vermont.gov/for-providers/clinical-coverage-guidelines�

http://www.dvha.vermont.gov/for-providers/clinical-coverage-guidelines�


************************************************************************ RADIOLOGY

Providers who choose to bill worker's compensation or accident insurance first, instead of Vermont Medicaid, will not be eligible for reimbursement if prior authorization is not obtained prior to the service being rendered.

(page 41)

Added:

************************************************************************ above red text to section


Providers who can bill Vermont Medicaid for smoking cessation counseling are physicians, nurse practitioners, licensed nurses, nurse midwives, and physician’s assistants.

(page 41)

Deleted: the above text

Added

Providers must code each claim with the correct diagnosis for tobacco use complicating pregnancy.

: Coverage applies when furnished by (or under the direction of) a physician or by any other health care professional who is legally authorized to furnish such services under state law and licensure.

************************************************************************ BREAST PUMPS

DME providers are allowed to bill using the mother’s name and UID; a diagnosis must be specified for the baby.

(page 47)

Added


3/01/2012 AUDIOLOGICAL SERVICES/HEARING AIDS

Coverage of audiology services is provided to beneficiaries of any age.

(page 15)

· Audiologic examinations; · Hearing screening; · Hearing assessments; · Diagnostic tests for hearing loss; · Analog hearing aids, plus their repair or replacement for beneficiaries of any age

· Digital hearing aids, plus their repair or replacement for beneficiaries of any age (see below for further instruction).

· Prescriptions for hearing aid batteries – six batteries per month (see below for further instruction); · Fitting/orientation/checking of hearing aids; and · Ear molds.

Payment will be made for hearing aids for beneficiaries who have at least one of the following conditions or if otherwise necessary under EPSDT found at rule 4100:

· Hearing loss in the better ear is greater than 30dB based on an average taken at 500, 1000, and 2000Hz.


· Unilateral hearing loss is greater than 30dB, based on an average taken at 500, 1000, and 2000Hz. · Hearing loss in the better ear is greater than 40dB based on an average taken at 2000, 3000, and

4000Hz, or word recognition is poorer than 72 percent.

Non-Covered Services:

Medicaid Rule, along with DVHA rules for the programs encompassed under “Medicaid” such as VHAP, pharmacy programs and premium assistance programs, is located online at

The following are non-covered services unless authorized for coverage via rule 7104: nonmedical items, such as: air canal aids and maintenance items other than batteries, and fees associated with selection and trial periods or loaners. DVHA does not pay for “CIC” (completely in the canal) hearing aids.

http://humanservices.vermont.gov/on-line-rules/dvha Added: above red text to section

Deleted

************************************************************************ : but payment of certain audiological services may be limited depending on the beneficiary’s age.

ANESTHESIA

Billable by the CRNA or Physician:

(page 14)

All anesthesia codes must be billed with the appropriate modifier. Reimbursement may be extended to the services of more than one anesthesiologist when written justification is attached to the claim with a copy of the operative report and the anesthesia record. Use modifier 22 (manual review) after the modifiers AA or QZ.

Deleted: Use modifier 22 (manual review) after the modifiers AA or QW

************************************************************************ MIDWIFE SERVICES

2. Antepartum visits are limited to a combined total of 15 per pregnancy, regardless of how many different providers have seen the beneficiary. One unit=one visit.

(page 31)

Replaced: above text with See OBSTETRICAL CARE

************************************************************************** for antepartum care visit billing instructions.

2/01/2012

ANESTHESIA (page 14)

Deleted

************************************************************************ : All anesthesia services billed to Vermont Medicaid must be billed as one unit = 15 minutes.

INDEPENDENT LABORATORY

The referring physician is the physician or practitioner who actually ordered the tests for the beneficiary; he or she must be enrolled as a participating or non-participating Vermont Medicaid provider. Enter the NPI/taxonomy code combination of the referring physician in field locators 17a and 17b. The billing provider name and address, to which payment will be made, must appear in field locator 33 and the NPI number must appear in field locators 33a and 24j.

(page 26)

Deleted

************************************************************************ : non-participating

PHYSICIAN’S ASSISTANT (page 37)

http://humanservices.vermont.gov/on-line-rules/dvha�


Physician assistants (PA) are eligible to enroll with Vermont Medicaid as active participating providers. The services of a physician’s assistant are limited to those allowed by their license and approved by the Vermont Board of Medical Practice.

Deleted: As of January 1st, 2010

Deleted

************************************************************************

: All active non-participating physician assistants are required to change their status, when their license expires, by completing and returning the provider enrollment agreement to the Provider Enrollment Unit, at HP Enterprise Services. The AM modifier will no longer be required once the PA has enrolled as an active-participating provider.

VISION CARE (page 42)

Eye Exams: Reimbursement for eye exams is limited to one comprehensive and one interim eye exam within a two-year period. Vermont Medicaid beneficiaries under the age of 21 are entitled to one pair of eyeglasses, and one fitting fee, within two years (Medicaid Rule 7316). In line with current DVHA policy related to dates of service, providers may bill eyeglass fitting fees on the day they order the glasses.

Added

************************************************************************

: above red text

PRESCRIBING PROVIDER

Doctors of Medicine (M.D.s), Doctors of Osteopathy (D.O.s), Nurse Practitioners (NPs), and certain other licensed practitioners may write prescriptions for DME and medical supplies. Audiologists may prescribe hearing aids. Physical and occupational therapists may prescribe wheelchairs and seating systems (MD endorsement of the prescription is required). Augmentative communication devices require a prescription by a speech/language pathologist with MD endorsement of the prescription. All written prescriptions must be legible, contain the required information and applicable dates. The physician/nurse practitioner prescriber must be enrolled as a participating or non-participating Vermont Medicaid provider and the prescribing/attending NPI number on the CMS 1500 claim must be a valid. When billing for services to Vermont Medicaid, the prescribing/referring physician NPI number should appear in field locator 17b on the CMS 1500 claim form.

(page 51)


Deleted

************************************************************************ : non-participating

1/11/2012 ANESTHESIA (page 14)

Units of Service:

The DVHA payment methodology for anesthesia services is the lower of the actual charge or the Medicaid rate on file. Under Level III PAC A pricing is the Medicare payment formula of (units of service + base unit) multiplied by a conversion factor. The units of service billed are based on Medicare billing requirements. The

Anesthesia services (procedure codes which begin with zero in the CPT) are required to bill units in actual time spent in minutes. For example, one unit equals one minute of actual time spent in attendance. A limit of 600 units (10 hours) has been imposed all anesthesia codes, with the exception for CPT codes 00211 and 00567 the unit limit is 480, and CPT code 01967 the unit limit is 360. When submitting a claim for anesthesia services with units greater than the maximum allowed amount for the same date of service; submit a paper CMS 1500 claim form and include the appropriate supporting documentation (e.g. an anesthesia report), except for code 01967 for which the unit cap is set.


base unit values used by DVHA are those put in place by Medicare effective January 1, 2012. For ongoing updates, the DVHA will follow Medicare's update schedule each January 1.

Added

************************************************************************ : above red text

1/1/2012 ANESTHESIA (page 14)

Units of Service: Anesthesia services (procedure codes which begin with zero in the CPT) must be billed in quarter hour units of service (one unit=15 minutes) for charted time only; do not add in the anesthesia base. Total minutes should be divided by 15 and rounded to nearest unit (i.e., .49 and under, round down and .5 and over, round up).

Deleted: above text

Units of Service:

When submitting a claim for anesthesia services with units greater than the maximum allowed amount for the same date of service; submit a paper CMS 1500 claim form and include the appropriate supporting documentation (e.g. an anesthesia report).

Anesthesia services (procedure codes which begin with zero in the CPT) are required to bill units in actual time spent in minutes. For example, one unit equals one minute of actual time spent in attendance. A limit of 600 units (10 hours) has been imposed on most anesthesia codes.

Added

************************************************************************ : above red text


Flu Shots Immunization for flu and pneumonia are available at little or no cost in Vermont via a program of the Vermont Agency of Human Services Department of Health. See the Vermont Immunization Manual at (http://healthvermont.gov/hc/imm/VermontImmunizationManual.aspx). Beneficiaries are encouraged to use this service. Local home health agencies and Area Agencies on Aging will administer flu vaccines in many locations around the state.

All vaccine administration fees must be supported with a vaccine code, even when there is no amount to be reimbursed.

Added

************************************************************************ : above red text

12/1/2011

Vermont Medicaid does not utilize the modifier combinations ‘RTLT’ or ‘LTRT’ (both right and left; bilateral). When Correct Coding allows one of these combinations on the base procedure code and the item is supplied bilaterally, the Vermont Medicaid provider must bill two separate line items: one with modifier RT on the base code and another line with modifier LT on the base code. The RT and LT modifier must appear first when used in combination with another modifier.

MODIFIER ‘LT’ & ‘RT’

Added

************************************************************************ : above red text

11/1/2011

http://healthvermont.gov/hc/imm/VermontImmunizationManual.aspx�


PSYCHIATRY/PSYCHOLOGY

99251 Inpatient consultation for a new or established patient 1 unit

(page 39)

Added

************************************************************************ : above red text

10/1/2011 FIELD LOCATOR (page 7)) 11d. IS THERE ANOTHER HEALTH BENEFIT PLAN* Check the appropriate box. If yes, complete

fields 9 a-c. Health benefits provided under Green Mountain Care are not considered other insurance. Other insurance only pertains to a private health insurance carrier.

REQUIRED INFORMATION

Added

************************************************************************ : above red text


Pharmacist-Administered Flu Shots for Adults

Reimbursement and billing: Under this program, pharmacies are reimbursed for the cost of the vaccine and an administration fee. No dispensing fee is paid for these claims. Pharmacists should bill DVHA using either the paper CMS-1500 claim form or the 837 electronic CMS-1500 claim form. A claim for the vaccine must accompany a claim for administration; therefore these vaccinations cannot be billed at POS through the pharmacy benefit. The appropriate billing codes to be used are as follows: Influenza vaccine codes: 90656, 90658 and administration code 90471.

Effective September 30, 2011, DVHA-enrolled pharmacies may be reimbursed for injectable influenza vaccinations administered by pharmacists to adults 19 years and older enrolled in Vermont’s publicly funded programs. Pharmacists must be certified to administer vaccines in the state of Vermont and must be in compliance with all Vermont laws governing vaccine administration. Failure to comply with all Vermont immunization regulations will subject these claims to recoupment. Reimbursement will be based on either a written prescription or a non-patient specific written protocol based on a collaborative practice agreement per state law. These orders must be kept on file at the pharmacy. The billing pharmacy and the ordering prescriber's NPI is required on the claim for the claim to be paid.

For instructions on billing with a CMS 1500 claim form, see the CMS-1500 Manual at: http://www.vtmedicaid.com/Downloads/manuals.html.

For information on reimbursement please refer to the Fee Schedule on the DVHA website:

If you have additional billing questions, please contact HP provider services at 800-925-1706. For other questions regarding this benefit, please contact a member of the DVHA pharmacy unit at 802-879-5900.

http://dvha.vermont.gov/for-providers/claims-processing-1

Added

************************************************************************ : above red text

NON-EMERGENCY MEDICAL TRANSPORTATION

Non-Emergency Medical Transportation (NEMT) is a covered service for beneficiaries enrolled in traditional, Primary Care Plus (PC Plus) Medicaid and the Dr. Dynasaur programs. NEMT is a statewide service, providing transports for eligible beneficiaries to and from medically necessary medical services that are Medicaid billable. It is provided through personal services contracts between the State of Vermont, Agency of Human Services (AHS), Department of Vermont Health Access (DVHA) and local public transit brokers.

(NEMT) (page 34)


http://dvha.vermont.gov/for-providers/claims-processing-1�


All providers are required to confirm a beneficiary's appointment when verification is requested from a Medicaid transportation provider. CMS requires transportation providers to verify that transportation is to and from eligible medical appointments. At this time, the DVHA requires transportation providers to verify 5% of all ride requests made by beneficiaries.

For further NEMT information and requirements go to http://dvha.vermont.gov/for-providers.

Added

************************************************************************ : above red text

OBSETRICAL CARE

External cephalic version (ECV) is only eligible for reimbursement for pregnancies at or beyond 36 weeks gestational age. Notes are required to confirm the service was performed. Only one ECV (successful or not) is reimbursable per pregnancy.

(page 36)

Added

************************************************************************ : above red text


Allowed place of service codes: 11-Office, 03-School (when not part of an IEP), 12-Home, 21-Inpatient Hospital, and 53-Community Mental Health Clinic.

(page 38)

Deleted

************************************************************************ : above text

RENTAL

The Department of Vermont Health Access has transitioned most, but not all rental reimbursements to rental (RR) logic. This logic calculates the rental modifier (RR) to allow 10% of the purchase price (rate on file) for the procedure code. Most but not all rental periods are 30 days. Providers are required to pro rate rentals when the rental period is less than 30 days.

(page 52)


Deleted:

************************************************************************

The DVHA’s monthly rental payment is calculated at one tenth of the DVHA purchase price. Payment will be made in monthly increments for equipment rented for a full month (30-31 days) or any portion thereof.

9/1/2011 OBSETRICAL CARE

When different physician groups provide OB care for the same pregnancy, total OB codes cannot be used. Please follow the Instructions below for all pregnancies that span dates in 2010 into 2011.

(page 33)

Instructions:

· Antepartum Care, billing 1-3 visits; use appropriate E/M codes for each visit

· Antepartum Care, billing 4-6 visits; use CPT code 59425 with the range of dates billed as 1 unit

· Antepartum Care, billing 7 or more visits; use CPT code 59426 with the range of dates billed as 1 unit

Example A: Beneficiary goes to Dr. A for 3 visits; Dr. A would bill the appropriate E/M code for each visit with each applicable date of service.



Beneficiary switches to Dr. B for the remainder of her pregnancy. Dr. B sees the beneficiary for 6 visits; Dr. B bills out ONLY code 59425 with range of days and 1 unit. If Dr. B delivers, he would also bill the appropriate delivery code.

Example B: Beneficiary goes to Dr. A for 5 visits; Dr. A bills 59425. Beneficiary then goes to Dr. B for one visit; Dr. B will ONLY bill the E/M code for the visit he provided. Beneficiary goes to Dr. C for 8 visits; Dr. C would bill 59426 with range of days and 1 unit. Dr. C delivers and would bill the appropriate delivery code.


************************************************************************

Deleted: Each prenatal/antepartum visit is billed using code 59425 (visits 1-6) and/or 59426 (visits 7 and up).


Face-to-face smoking cessation counseling is covered for pregnant Vermont Medicaid beneficiaries. The maximum number of visits allowed per calendar year is 16. Providers who can bill Vermont Medicaid for smoking cessation counseling are physicians, nurse practitioners, licensed nurses, nurse midwives, and physician’s assistants. “Qualified” Tobacco Cessation Counselors are also allowed (requires at least eight hours of training in tobacco cessation services from an accredited institute of higher education).

(page 39)

Added

************************************************************************ : above red text

8/1/2011 DEVELOPMENTAL & AUTISM SCREENING OF YOUNG CHILDREN

The American Academy of Pediatrics recommends that all infants and young children be screened with valid, reliable screening instruments for developmental delays at regular intervals. To improve detection rates through the use of standardized screening instruments by primary care providers, the DVHA will reimburse for a developmental screening (CPT 96110) with a standardized screening tool to be billed on the same day as a well-child visit or other E & M codes.

(page 18)

All infants or young children should have a general periodic developmental screening at the 9th, 18th, 24th or 30th month well child visits. Developmental screening is recommended when surveillance indicates an infant or young child may be at risk for developmental delay.

Primary Care Providers must use a standardized screening tool to bill for developmental screening that occurs in conjunction with a well-child visit or other visit. Any standardized screening tool listed in the Academy of Pediatrics policy statement Identifying Infants and Young Children with Developmental Disorders in the Medical Home (Pediatrics, Vol. 18, #1, July 2006) can be used through December 31, 2011. As of January 1, 2012 reimbursement will only be made when using the standardized screening tools listed at the bottom of this guidance.

When billing for a general developmental screening of an infant or young child at the 9th, 18th, 24th or 30th month visits providers should use CPT Code 96110 and the appropriate "V" diagnosis code. Providers are required to maintain documentation in the patient medical record of the screening, the screening tool used, and evidence of screening result or screening score. When billing for a general developmental screening and an autism screening (see Autism Screening) on the same day, each procedure must be on its own line. Billing two units of 96110 will result in the claim being denied.

To ensure children are screened with the most appropriate tools, the Vermont Child Health Improvement Program reviewed information on developmental screening tools identified in the AAP policy statement, and


coordinated a committee of developmental and primary care pediatricians to review and comment on this information resulting in a “preferred list” of developmental screening tools.

For most primary care physicians, tools that fall under the general screening category are going to be most useful and appropriate for young children. There will be instances where secondary screening tools, or domain specific tools, may be appropriate, and the decision to use such tools should be based on individual practice needs, physician experience, population needs, etc.

· Ages & Stages Questionnaire (ASQ) Third Edition (2009)

General Screening Tools

www.agesandstages.com

· Battelle Developmental Inventory: 2nd Edition (BDI-II) - Screening Test (2006) www.riverpub.com

· Bayley Scales of Infant and Toddler Development: 3rd Edition (Bayley-III) Screener (2005) www.pearsonassessments.com

· Brigance Early Childhood Screens (2005) www.curriculumassociates.com

· Infant Development Inventory (IDI) (1998) www.childdevrev.com

· Parents’ Evaluation of Developmental Status (PEDS) (1997) www.pedstest.com

· PEDS: Developmental Milestones (2006) www.pedstest.com

· Ages & Stages Questionnaires: Social-Emotional (ASQ:SE)

Secondary Screening Tools

www.agesandstages.com

· Child Behavior Checklist (CBCL) Achenbach System http://www.aseba.org/

· Communication and Symbolic Behavior Scale-Developmental Profile (CSBS-DP):Infant Toddler Checklist http://www.brookespublishing.com/store/books/wetherby-csbsdp/index.htm

· Early Language Milestone Scale (ELM Scale-2) http://www.proedinc.com/customer/ProductLists.aspx?SearchWord=ELM

· Language Development Survey http://www.aseba.org/

· Alberta Infant Motor Scale (AIMS) (1994) http://www.us.elsevierhealth.com/product.jsp?isbn=9780721647210

The AAP recommends that young children should be screened with valid, reliable screening tool for autism at regular intervals. All children should have an autism specific screening at the 18th and 24th month well child visits. To improve detection rates through the use of standardized screening tool by primary care providers, the DVHA will allow for an autism screening (CPT 96110) with a standardized screening tool to be billed on the same day as a well-child visit or other E & M codes.

Autism Screening

The AAP recommends that young children be screened with a valid, reliable screening tool for autism at regular intervals. All children should have an autism specific screening at the 18th and 24th month well child visits. To improve detection rates through the use of a standardized screening tool by primary care providers, the DVHA will allow for an autism screening (CPT 96110) with a standardized screening tool to be billed on the same day as a well-child visit or other E & M codes.

Primary care providers must use a standardized screening tool to bill for autism screening that occurs in conjunction with a well-child visit or other visit. Any standardized screening tool listed in the Academy of Pediatrics policy statement Identifying Infants and Young Children with Developmental Disorders in the Medical Home (Pediatrics, Vol. 18, #1, July 2006) can be used through December 31, 2011. As of January 1,

http://www.agesandstages.com/�

http://www.riverpub.com/�

http://www.pearsonassessments.com/�

http://www.curriculumassociates.com/�

http://www.childdevrev.com/�

http://www.pedstest.com/�

http://www.pedstest.com/�

http://www.agesandstages.com/�

http://www.aseba.org/�

http://www.brookespublishing.com/store/books/wetherby-csbsdp/index.htm�

http://www.proedinc.com/customer/ProductLists.aspx?SearchWord=ELM�

http://www.aseba.org/�

http://www.us.elsevierhealth.com/product.jsp?isbn=9780721647210�


2012, reimbursement for child autism specific screening at the 18th and 24th month visits should only be requested when the standardized screening tool listed at the bottom of this guidance is used.

When billing for autism specific screening at a visit, providers should use CPT Code 96110 with the modifier 59 and the appropriate "V" diagnosis code.

When billing for an autism screening and a general developmental screening (see Developmental Screening, above) on the same day, each procedure must be on its own line. Billing two units of 96110 will result in the claim being denied.

Modified Checklist for Autism in Toddlers (MCHAT) (1999)

Preferred tool list for autism specific screening:

http://www.firstsigns.org/screening/tools/rec.htm#asd_screens


The AAP recommends that all infants and young children should be screened with valid, reliable screening instruments for developmental delays at regular intervals. To increase the use of standardized screening instruments and to improve detection rates, the DVHA will allow billing for the well-child visit and the developmental screening on the same day when a standardized screening instrument is used. Changes in the billing are to allow a developmental screening to be billed by Primary Care Providers with the preventive medicine services CPT codes on the same day for children less than 21 years of age in Medicaid, Dr. Dynasaur, or SCHIP.

DEVELOPMENTAL & AUTISM SCREENING

Physicians or Primary Care Providers must use a standardized screening instrument to bill for developmental screening that occurs in conjunction with a well-child visit. Any standardized screening instrument listed in the Academy of Pediatrics policy statement will be accepted at this time. Providers are required to maintain documentation of the screening and the screening instrument used in the beneficiary’s record.

Developmental screening is recommended when surveillance indicates the child may be at risk for developmental delay. In addition, all children should have periodic developmental screening at the 9th, 18th, 24th or 30th month visits. In addition, an autism specific screening is also recommended at the 9th and 18th month visits.

Deleted

************************************************************************ : above text

FACTOR HCPCS CODES

Factor HCPCS Codes are typically submitted through the pharmacy benefit (except in cases of emergency). Claims for services billed thought the medical benefit require notes be included. All claims submitted for emergency room services are exempt from this requirement.

(page 22)

Added

************************************************************************ : above red text

MEDICAL NUTRITION THERAPY

DVHA will enroll Registered Dietitians (RD) as a non-participating provider and assign a Vermont Medicaid Provider number which will allow their provider number to appear on the CMS 1500 claim form as the attending provider, i.e., the provider of the service for that day. The billing provider for the CMS 1500 claim form must be a hospital, physician or school.

(page 29)

http://www.firstsigns.org/screening/tools/rec.htm#asd_screens�


The Registered Dietitians will be enrolled as participating providers for the Family Infant and Toddler Program & Children with Special Health Needs only. When a beneficiary is eligible for FITP or CSHN only, the claim will process when the RD is the attending and billing provider.

FQHC/RHC certified diabetic educators and registered dieticians services are payable for one on one face to face encounters.

Deleted: above text Added

************************************************************************

: red text in the following sentence: This service is paid through the enrolled primary care physician, inpatient hospital, outpatient Hospital, registered dietitians (RD) and school health services.

VISION CARE

Fitting of Spectacles codes are limited to one every two years. (page 41)

Deleted

************************************************************************

: codes are limited to one every two years.

33. BILLING PROVIDER* Enter the

7/1/2011 payee

provider name and address (Individual provider format: last name, first name)

Added

************************************************************************ : above red text (page 8)

OVER-THE-COUNTER (OTC) MEDICATIONS

Effective July 1, 2011, coverage of Over the Counter (OTC) medications will be primarily limited to generics only in categories determined to be medically necessary. All other OTC products will be excluded from coverage without the option for a prior authorization request through the Clinical Call Center. The new coverage guidelines apply to all state pharmacy benefit plans, e.g., Medicaid, Dr. Dynasaur, VHAP, and includes VPharm, our Part D “wrap” program. OTC coverage in our “limited OTC” plans such as VScript Expanded and VPharm 3 will not change. As a reminder, DVHA only pays for OTCs when there is a specific medical necessity, and you must write a prescription for the OTC product. Some OTC medications are already managed on our Preferred Drug list (PDL) and other restrictions may apply. Though we have restricted OTC medications to primarily generics, beneficiaries will continue to have at least one choice in all medically necessary drug categories. Please refer to our website for a list of covered OTC medication categories at

(page 33)

http://dvha.vermont.gov/for-providers The PDL can be found at http://dvha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria.

Added

************************************************************************ : Section

RADIOLOGYEffective July 1, 2011, the DVHA will implement a multiple procedure payment structure for CT, CTA, MRI and MRA imaging procedures. This structure will apply whenever multiple outpatient imaging services using the same or similar modality (MRI and MRA, CT and CTA) are performed on the same day, by the same provider, on contiguous body areas.

(page 36)





In these cases, the procedure with the highest intensity will be paid at 100% of the fee schedule rate and subsequent procedures will be reimbursed at a lower rate. If two procedures are performed, the second procedure will be reimbursed at 50% of the fee schedule rate. The third and all subsequent procedures will be paid at 25% of the fee schedule rate. This rate structure applies only to the imaging procedure component of the claim. The professional (physician) component is not affected by this change.

Added


5/1/2011 AMBULANCE SERVICE

(page 12) FROM SERVICE TO ALLOWED

7. Home or nursing home Physician’s office No

8. Physician’s office Home or nursing home No

Added

************************************************************************


3/1/2011 VISION CARE (page 38)

Eyeglasses: Coverage for eyeglasses (frames and/or lenses) is limited to one pair of glasses every two years per beneficiary. Reimbursement for earlier replacement is limited to the following: eyeglasses (frames and/or lenses) have been lost or broken beyond repair and either of these reasons is indicated on the claim form in the Notes field. Replacement of the original prescription constitutes new glasses and the beginning of the two year limitation period. Other reasons such as prescription/diopter change, scratched lenses, frame size or other special need will require prior authorization from the DVHA Clinical Operations Unit. See: Prior Authorization below.

· Fitting of Spectacles codes are limited to one every two years. There are several Fitting of Spectacles codes for use when fitting a new pair of eyeglasses to the beneficiary; please view the CPT descriptions to select the most appropriate billing code. These fitting fee codes are also used if glasses are replaced if lost or broken beyond repair. Your claim must indicate the circumstance in form locator 19 on the CMS1500 or electronically in the Notes section. One fitting fee code applies, whether one or both eyes are involved.

Procedure Codes - Fitting vs. Repair and Refitting:

· Repair and Refitting Spectacles codes are used for the in-office repair of spectacles. Codes for Repair and Refitting Spectacles are not applicable when ordering frames, lenses or eyeglasses or for replacement. Please view the CPT descriptions to select the most appropriate billing code.

Prior Authorization of Services PA can be requested by completing the Eyeglass Medical Necessity form (MNF), available at http://dvha.vermont.gov/for-providers/forms-1. The requesting/dispensing provider's NPI and Taxonomy combination must be listed on the MNF. The same NPI # and corresponding provider

http://dvha.vermont.gov/for-providers/forms-1�


name must be given in fields 7.a. and 7.b. on the Chadwick prescription claim form (Vision Care Invoice).

Prior Authorization change requests must come from the original requesting provider. The PA change request to update an existing prior authorization must be in the form of a detailed letter referencing the PA #, stating the change(s) requested, and explaining why the change is needed. A copy of the existing PA is not necessary.

All provider numbers must be the NPI #, per federal regulation (do not use the Medicaid ID #). Added


2/1/2011

CHILDREN WITH SPECIAL HEALTH NEEDS/FAMILY INFANT TODDLER PROGRAMS

Dental claims for Children with Special Health Needs will continue to be processed through the Vermont Department of Health, PO Box 70, Burlington, VT 05402.

(page 16) Aid Category Code – SH (Children with Special Health Needs) is used only when submitting medical claims for Physical, Occupational and Speech Therapy (PT,OT,ST), Nutritionist (NU) or Autism Specialist (AU) services only.

Added

************************************************************************ : section

CLAIM SUBMISSION (page 17) Submit all paper claim requests to: HP Enterprise Services, PO Box 777, Williston, VT 05495-0888

Added

************************************************************************ : section


Replaced: 80% with 71% Replaced: 88% with 86%

(page 34) (AJ is reimbursed at 80% of allowed amount and AH is reimbursed at 88% of allowed amount).

************************************************************************

1/1/2011 FIELD LOCATOR (page 7) 19. LOCAL USE Use this field to explain unusual services or

circumstances and to indicate a specific page number of a multiple page claim.

REQUIRED INFORMATION

Added

************************************************************************ : above red text

MULTIBLE PAGE CLAIMS (page 29) When billing a multiple page claim, you must indicate "page x of y" in Box 19, "Local Use" of the CMS-1500


claim form. To indicate the conclusion of the entire claim, field 28 of the last page of the claim must also include the total billed amount.

Example: page 1 of 3 (1st page of claim), 2 of 3 (2nd page of claim) & 3 of 3 (3rd page of claim). Added

************************************************************************ : above section

12/01/2010 PSYCHIATRY/PSYCHOLOGY

90846 Family Psychotherapy w/out Patient Present 1 unit=1 day Limited to 12 units per calendar year

(page 33)

Added:

************************************************************************ above red text

11/01/2010 HYSTERECTOMY (page 23) Note: No prior authorization is required, if the procedure billed is hysterectomy with the primary diagnosis indicating cancer of the genital system.

Added:

************************************************************************ above red text

MEDICAL NUTRITION THERAPY (page 27) FQHC/RHC certified diabetic educators and registered dieticians services are payable for one on one face to face encounters.

Added:

************************************************************************ above text to section

MASTECTOMY

Prior Authorization is not required for reconstructive breast surgery if the primary diagnosis indicates malignant neoplasm of the breast/breast cancer.

(page 27) Mastectomy procedures will be restricted to a diagnoses involving benign and malignant neoplasm of the breast. When the primary diagnosis is any other, documentation is required to be submitted with the claim to substantiate medical necessity."

Added:

************************************************************************ above section

VISION CARE

Eye Exams: Coverage for comprehensive eye exams and interim eye exams are limited to one exam every two years per beneficiary. A repeat comprehensive exam within 24 months requires prior authorization. All refraction exams are covered.

(page 37) Enrolled Medicaid providers will not be reimbursed by Vermont Medicaid for services to Medicaid beneficiaries age 21 and over for frames, lenses, dispensing and repairs. This also applies to VHAP beneficiaries 18 years of age and older and to all VHAP Pharmacy beneficiaries

The following procedure codes should be used when billing for vision services:


Procedure Codes:

92340, 92341, 92342, 92352, 92353, 92354, 92355 & 92358

Fitting fees are limited to one every two years. There are several fitting of spectacles codes available for use when fitting a new pair of eyeglasses to the beneficiary; new eyeglasses would not require repair. One fitting fee code applies, whether one or both eyes are involved: When billing for this service, please view the CPT descriptions to select the most appropriate billing code:

Repair and Refitting

92370 & 92371

Refitting services are only to be used in conjunction with the repair of glasses. Providers are instructed in accordance with correct billing, not to bill for repair and refitting services on the same day as new lenses and/or frames.

-When eyeglasses (frames and or lenses) have been lost, broken beyond repair, or scratched to the extent that visual acuity is compromised. Dispensing providers will make the decision about being broken beyond repair or visual acuity is being compromised. Prior authorization by the DVHA Clinical Unit is required for replacement of eyeglasses, other than those that are lost or broken beyond repair, within the two years.

· Lenses may be placed in the beneficiary’s own frames if the lenses can be incorporated safely

and reasonably into those frames, as determined by the sole source contractor.

· When there is a medical reason for special frames or lenses not within VT Medicaid’s sole-source contract, the prescribing optometrist or ophthalmologist needs prior authorization from DVHA and must complete the special instruction field on the order form that they send to the sole-source contractor. This applies for new lenses when Chadwick determines that the beneficiary's current lenses cannot be incorporated safely and reasonably into the special frames

Added: above text

Deleted: The special instructions must give a clear explanation of the special need and the reasons for it. Deleted:

************************************************************************

When there is a medical reason for purchasing special frames (not within VT Medicaid’s sole-source contract) and the beneficiary's current lenses cannot be incorporated safely and reasonably into the special frames (as determined by the sole source contractor), then the new lenses will also need prior authorization."

10/01/2010 SECTION 1.1

CMS 1500 BILLING INSTRUCTIONS (page 6)

Replaced1a. INSURED’S ID NUMBER* Enter the Vermont Medicaid ID number as

shown on the beneficiary’s Member ID card.

: Required Information text.

Enter the nine-digit Vermont Medicaid ID number as shown on the beneficiary’s Vermont Medicaid ID card.

************************************************************************ INPATIENT NEWBORN SERVICES (For Physicians) (page 25)


Form Locator

1a Mother’s Vermont Medicaid ID number 19 Write “billing for baby under mother’s ID number”.

Information

Replaced: SSN number with ID number under the Field Locator Information column.

Deleted:

************************************************************************ (Temporary ID numbers as only issued by the DFC and only issued if applying to a state program.)

09/01/2010 RADIOLOGY (page 34) High-tech outpatient elective diagnostic imaging scans for dates of service on or after September 1, 2010, require prior authorization from MedSolutions. Diagnostic Imaging Program Guidelines and other provider resources are available at vtmedicaid.com/Downloads/manuals.html

Added:

************************************************************************

above red text

08/09/2010 MILEAGE

If the beneficiary is able to take the DME item that needs to be repaired to the vendor, that is the expectation. Charges for delivery of a DVHA reimbursed DME item, cannot be made to Vermont Medicaid or to a beneficiary.

(page 42) Mileage incurred by providers associated with the repair of a DME item, is reimbursable by Vermont Medicaid and cannot be charged to the beneficiary. The mileage is billed with procedure code K0739. The mileage should be determined from their closest facility and if the vendor is providing multiple deliveries, the only portion that will be reimbursed is the portion of the mileage specific to the Vermont Medicaid beneficiary.

Replaced: procedure code E1340 with K0739.

************************************************************************

07/28/2010 PSYCHIATRY/PSYCHOLOGY

90853 Group Therapy Limited to a maximum of eight units per day, 1 unit=15 min. 1 session per day and 3 sessions per week, for each recipient

(page 33)

Added:

************************************************************************ above red text

Replaced: The Office of Vermont Health Access (OVHA) with the Department of Vermont Health Access (DVHA), throughout supplement.

************************************************************************

Payment for orthotics and prosthetics, including ostomy supplies and elastic stockings, may be made to the DME vendor when furnished to beneficiaries in residential facilities, including nursing homes. The doctor and

DME IN HEALTHCARE INSTITUTIONS (page 40)

http://vtmedicaid.com/Downloads/manuals.html�


vendor must keep a medical necessity form and/or order, completed by the physician, and/or other documentation of medical need in the beneficiary’s record.

Replaced:

************************************************************************

other than health care facilities with including nursing homes

INJECTIONS (page 24) Reimbursement for immunization codes is for the cost of the product only. When a vaccine has been provided free of charge to the practice, providers should use modifier SL with appropriate procedure code and report the charge as $0.00 to assure correct payment.

All in-state providers MUST obtain vaccines through the Vermont Department of Health (VDH) Vaccine for Children Program, for children through age 18. Influenza and H1N1 vaccines may be obtained through VDH; however it is not a requirement. The SL modifier must be used with an appropriate procedure code when billing the CPT or HCPCS code to assure correct payment. Report the charge as $0.00 to represent the free vaccine.

.Deleted: above text

Vaccines provided to adults over 18 or vaccines provided by out of state providers to patients of any age, do not have to be obtained by the VDH Vaccine Program. The SL modifier will not be required in either of those circumstances and payment will be based on the current fee schedule.

Added

************************************************************************

: above text

05/26/2010

TOPICAL FLORIDE VARNISH (page 36) Physicians, naturopaths, nurse practitioners and physicians assistants with one of the following specialty types: general practice, family practice, internal medicine, pediatric medicine, nurse practitioner, family practitioner, naturopathic physician with childbirth endorsement & without childbirth endorsement and pediatric practitioner are allowed to administer and bill for Topical Fluoride Varnish (HCPCS Code D1206) treatments for children ages 0-5.

Added:

************************************************************************

new section

CMS 1500 BILLING INSTRUCTIONS

04/12/2010

24h. EPSDT/FAMILY PLAN (page 8)

Deleted

************************************************************************

: 5-Ladies First

AMBULANCE SERVICES (page 11) The DVHA does not accept the modifiers utilized by Medicare. Effective January 1, 2010 Air mileage is no longer included within the ambulance service code and may be billed out separately.

Added

Deleted: is not to

: red test

************************************************************************CLIA (see also laboratory charges page 26)


Added: red text ************************************************************************DEVELOPMENTAL & AUTISM SCREENING (page 17) Developmental screening is recommended when surveillance indicates the child may be at risk for developmental delay. In addition, all children should have periodic developmental screening at the 9th, 18th, 24th or 30th month visits. In addition, an autism specific screening is also recommended at the 9th and 18th month visits.

Added: red text

***********************************************************************PHARMACY TAX ASSESSMENT FORM A monthly assessment is due to the State of Vermont for each prescription fill or refill sold by retail pharmacies. This applies to all scripts, and not only to Vermont Medicaid scripts. The amount of the assessment is $0.10 for each prescription fill or refill. The completed Pharmacy Assessment Monthly Documentation Form, available online at: http://ovha.vermont.gov/for-providers/pharmacy-forms along with additional information regarding the tax, needs to accompany each monthly payment. Chain pharmacies with more than one NPI number should complete a separate form for each facility every month.

Note: The Pharmacy Benefit Management Program Provider Manual is located at http://ovha.vermont.gov/for-providers under the Pharmacy section. The Pharmacy Benefit Management Program is for prescription drugs dispensed by retail pharmacies.

Move: see Provider Manual

************************************************************************

LABORATORY CHARGES (page 26) providers submitting claims for laboratory services are required to have a CLIA certificate on file with HP. The services being submitted must be covered by the certificate and within the effective dates. HP requires a copy of the most current CLIA certificate used by each individual provider, group or facility be sent directly to HP Enterprise Services, Provider Enrollment Unit, PO Box 888, Williston, VT 05495. Please be sure to include your NPI and Taxonomy Code(s) when mailing your copy to HP.

Additionally, Vermont Medicaid will utilize the QW modifier to indicate a CLIA waived tests following CMS guidelines for billing waived tests. To determine if your lab service requires a QW modifier please refer to the list published at: http://www.cms.hhs.gov/CLIA/downloads/waivetbl.pdf. Added: above test

Deleted: providers must furnish a copy of their current CLIA when enrolling/recertifying with Vermont Medicaid. For additional information, please contact EDS Enrollment, P.O. Box 888, Williston, VT 05495, (800) 925-1706 (in state) or (802) 878-7871 (out of state).

************************************************************************

MAINTENANCE DRUG PRESCRIPTIONS (page26) Maintenance drugs must be prescribed and dispensed for not less than 30 days and not more than 90 days, to which one dispensing fee will be applied. Excluded from this requirement are medications which the beneficiary takes or uses on an “as needed” basis or generally used to treat acute conditions. If there are extenuating circumstances in an individual case that, in the judgment of the prescriber, dictate a shorter prescribing period for these drugs, the supply may be for less than 30 days as long as the prescriber prepares in sufficient written detail a justification for the shorter period. The extenuating circumstance must be related




to the health and/or safety of the beneficiary and not for convenience reasons. It is the responsibility of the pharmacy to maintain in the beneficiary’s record the prescriber’s justification of extenuating circumstances. In these circumstances, regardless of whether or not extenuating circumstances permit more frequent dispensing, only one dispensing fee may be billed. Added: above red text test Deleted: The full list of classes of drugs affected by this change is available at: http://ovha.vermont.gov/for-providers. See OVHA’s Clinical Criteria document for drugs with other quantity limits: http://ovha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria ************************************************************************ NDC Requirements on CMS 1500 Form: (page 29) ************************************************************************

PHYSICIAN'S ASSISTANT (page 31) As of January 1st, 2010, physician assistants (PA) are only eligible to enroll with Vermont

Medicaid as active participating providers. All active non-participating physician assistants are required to change their status, when their license expires, by completing and returning the provider enrollment agreement to the Provider Enrollment Unit, at HP Enterprise Services. The AM modifier will no longer be required once the PA has enrolled as an active-participating provider.

Added: above red text test Deleted: Physician’s assistants may not bill independently therefore, the attending provider NPI must be that of the responsible physician. Services rendered by a physician’s assistant must be billed with the AM modifier, which indicates the service was performed by the physician assistant him/herself. The responsible physician’s NPI number must be given as the attending on the claim.

-Consultations are limited to one unit per date of service -Initial consultations are limited to one consult per related diagnosis per attending provider

Physician’s assistants may bill the following without a modifier, with the responsible physician’s NPI number:

-Laboratory tests -Injected Medications

************************************************************************

VISION CARE (page 36) Deleted: Eyeglasses must be purchased under the state's sole-source contract.

Deleted: DCF

Added: Reimbursement for additional services is limited to the following circumstances:

Added: the state

************************************************************************

12/31/2009

MEDICAL NUTRICIAN THERAPY (new, page 27) This service is paid through the enrolled primary care physician, inpatient hospital, outpatient hospital and



http://ovha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria�


school health services. OVHA will enroll Registered Dietitians (RD) as a non-participating provider and assign a Vermont Medicaid Provider number which will allow their provider number to appear on the CMS 1500 claim form as the attending provider, i.e., the provider of the service for that day. The RD may use three codes that are specific to RDs, and that cannot be billed for service by the physician. The billing provider for the CMS 1500 claim form must be a hospital, physician or school.

The Registered Dietitians will be enrolled as participating providers for the Family Infant and Toddler Program & Children with Special Health Needs only. This means when a beneficiary is eligible for FITP or CSHN only, the claim will process when the RD is the attending and billing provider.

************************************************************************ VISION CARE (Page 37)

Changed: the word days to months

***********************************************************************

PHARMACY TAX ASSESSMENT FORM (Page 32) A monthly assessment is due to the State of Vermont for each prescription or refill sold by retail pharmacies. This applies to all scripts, and not only to Vermont Medicaid scripts. The amount of the assessment is $0.10 for each prescription and refill. The completed Pharmacy Assessment Monthly Documentation Form, available online at: http://ovha.vermont.gov/for-providers/pharmacy-forms along with additional information regarding the tax, needs to accompany each monthly payment. Chain pharmacies with more than one NPI number should complete a separate form for each facility every month.

Added: the word TAX in title

Added: the word fill and or

Deleted: the word and

***********************************************************************8/25/2009 BICROS/CROS (Contralateral Routing of Sound) (Page 40) Vermont Medicaid does not cover CROS (Contralateral Routing of Sound) and BICROS hearing aids and related services.

Per review of current medical literature, the effectiveness of these aids is unproven. Related current HCPCS procedure codes are in the range of V5170-V2540.

************************************************************************ DME BILLING (Page 40) When billing for DME items, the date of service must be the date the item was delivered to the beneficiary. The date of service may not be any earlier than the date of delivery. For items that are custom ordered, the evaluation, fitting, casting and taking of measurements is included in the allowance of the item. There is no separate payment allowed. Providers may not seek additional reimbursement for this.

************************************************************************

SPECIAL NEEDS FEEDER BOTTLES (Page 46) HCPCS procedure code S8265 is accepted by Vermont Medicaid to bill for the Haberman Feeder (special needs bottle with nipple) when medically necessary for dysphasia due to cleft lip/palate. When the cause of the dysphasia is other than cleft lip/palate or the bottle is not Haberman, unlisted procedure code A9999 is allowed.



All special needs feeder bottles are reusable, must be ordered by a physician, and supplied by a DME/pharmacy vendor. Quantity is limited to 10 bottles with nipples per six months. Prior authorization is not required. The medical need must be clearly documented in the patients’ medical records and an invoice is required with each claim submission.

(07/24/2009) MAINTENANCE DRUG PRESCRIPTIONS (Page 26) Effective August 1, 2009: When the OVHA is the primary payer, pharmacies are required to dispense designated classes of maintenance drugs in 90-day supplies after the first fill. In addition, when the OVHA is the primary payer, prescriptions written for maintenance drugs must be rewritten for 90 days for the drug to be covered. The maximum quantity limit of 102 days still applies. This rule does not apply to beneficiaries who have other primary insurance, including Part D. The full list of classes of drugs affected by this change is available at: http://ovha.vermont.gov/for-providers. See OVHA’s Clinical Criteria document for drugs with other quantity limits: http://ovha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria.

************************************************************************APNEA MONITORS (Page 39) Vermont Medicaid covers the rental of an Apnea Monitor for use in the home when medically necessary, as per the OVHA Clinical Criteria, however purchase is not covered. The OVHA Clinical Guidelines for Apnea Monitors is available online at: http://ovha.vermont.gov/for-providers/apnea-monitor-04-01-09.pdf.

For beneficiaries under the age of one year (infants), prior authorization is not required. When the condition(s) which caused a need for the monitor have been resolved or stable for two to four months, monitor rental must be discontinued.

************************************************************************ DME RECYCLING (Page 40) (This refers to all vendors of DME who provide the following equipment to Medicaid beneficiaries, with the exception of dual eligible beneficiaries whose primary insurance will cover the cost of the device): -Manual Wheelchairs -Power Operated Vehicles -Power Wheelchairs -Standers -Lifts -Hospital Beds -Rehab Shower Commode Chairs -Augmentative Communication Devices/Speech Generating Devices

Beginning July 15, 2009, all vendors who provide this equipment will be required to affix a sticker on the item at the time of service delivery. This sticker will identify Medicaid as the owner of the device and will provide contact information regarding return of the device when it is no longer required by the beneficiary. Medicaid will provide these stickers. Stickers must be applied to an area of the device that is protected from daily wear and tear but is visible without excessive effort.

There will also be an accompanying signature sheet to be signed by the vendor and the beneficiary or their legal guardian. This form shall be kept on file at the vendor’s office and be available for inspection and a copy provided to the beneficiary for their records. This form will be available on the OVHA and EDS website and is listed as the Durable Medical Equipment Ownership, Operation, and Maintenance Agreement.

Contact the OVHA at 802-879-6396 to obtain stickers and forms if you have not received them by July 1, 2009 or if you run out.

************************************************************************


http://ovha.vermont.gov/for-providers/preferred-drug-list-clinical-criteria�

http://ovha.vermont.gov/for-providers/apnea-monitor-04-01-09.pdf�


(06/05/2009) SECTION 1.3 NON-REIMBURSABLE SERVICES (Page 8)

No payment will be made for a service or item that is not reimbursable, unless authorized by the OVHA for reimbursement via section M108 of Medicaid rules.

Deleted: ...M108 of the Welfare Assistance Manual

************************************************************************ ANESTHESIA (Page 13) Units of Service: Anesthesia services (procedure codes which begin with zero in the CPT) must be billed in quarter hour units of service (one unit=15 minutes) for charted time only; do not add in the anesthesia base. Total minutes should be divided by 15 and round to nearest unit (i.e. .49 and under round down .5 and over round up).

************************************************************************ CAST, SPLINT AND STRAPPING MATERIALS (Page 15) Materials for casting, splinting and strapping, etc., are payable. Refer to your HCPCS listing for a full description of the allowed codes.

Casting supplies are used by physician and rehabilitative therapy providers and are billed by the provider who incurs the cost.

************************************************************************ CHIROPRACTIC SERVICES (Page 15) Effective as of a July 15, 2009 date of service, reimbursement for adult chiropractic services is reinstated for procedure codes 98940, 98941, and 98942. These chiropractic manipulative treatment codes include a pre-manipulation patient assessment.

The OVHA will not pay for any x-rays necessary to substantiate the subluxation.

Physicians, hospitals and other providers should be aware that Vermont Medicaid does not pay for any service ordered by a chiropractor.

Beneficiaries under age 21 may only receive chiropractic services for the manipulation of the spine to correct a subluxation. Chiropractic services for beneficiaries under age 12 require prior authorization from the OVHA. Visits are limited to 10 visits per calendar year. In order for children to get more than ten visits in a calendar year, the chiropractor will need to seek prior authorization from the OVHA. Pertinent clinical data documenting the need for treatment must be submitted in writing.

Guidelines for required data are available from the OVHA at: http://ovha.vermont.gov/for-providers.

Deleted: As of February 1, 2009, Vermont Medicaid will not reimburse for chiropractic services for Vermont Medicaid beneficiaries age 21 and over. This also applies to VHAP beneficiaries 18 years of age and older.

******************************************************************************

FQHC/RHC (Page 20) Federally Qualified Health Centers and Rural Health Clinics have at least two provider numbers-one for services paid at cost and one paid per fee schedule. Services paid at cost are billed as encounters.

A. Encounters:

An encounter at a FQHC/RHC is defined as a face-to-face visit between a beneficiary and a provider. Face-to-face visits with more than one health professional for similar diagnoses, or face-to-face visits


with more than one health professional of the same type, or multiple face-to-face visits with the same health professional on the same day at the same location, generally constitutes a single encounter. Centers must bill procedure code T1015 for the encounter in addition to CPT/HCPCS codes for the services rendered. The T1015 encounter code should be billed with a zero charge amount or a negligible charge amount (i.e., $.01 or $1.00) if your software prohibits using a zero charge amount for electronic billings. CPT/HCPCS codes for the services must be billed using your usual and customary charge.

************************************************************************ INTERPRETER (Page 25) When a Vermont Medicaid provider pays interpreter services for a beneficiary (who does not speak the same language as the provider), in person (at the office) or over the phone – or for the use of sign language (with a hearing impaired beneficiary), the provider may bill procedure code T1013 for every 15 minutes of service provided. FQHC/RHC providers must bill T1013 for interpreter services using their non-FQHC/RHC provider numbers.

Home Health Agencies must use revenue code 940 along with the HCPCS code T1013.

************************************************************************ PHARMACY ASSESSMENT FORM (Page 30) A monthly assessment is due to the State of Vermont for each prescription or refill sold by retail pharmacies. This applies to all scripts, and not only to Vermont Medicaid scripts. The amount of the assessment is $0.10 for each prescription and refill. The completed Pharmacy Assessment Monthly Documentation Form, available online at: http://ovha.vermont.gov/for-providers/pharmacy-forms along with additional information regarding the tax, needs to accompany each monthly payment. Chain pharmacies with more than one NPI number should complete a separate form for each facility every month.

************************************************************************ PHYSICIAN VISIT LIMITS Pursuant to Medicaid Rule M614, the following physician visit limits apply…

Deleted: …WAM

************************************************************************ TAMPER-RESISTANT PRESCRIPTION DRUG PADS (Page 35) CMS has indicated that as of 10/01/2007, all written prescriptions for outpatient covered drugs must be written on tamper-resistant prescription paper. CMS requires the Medicaid agencies audit pharmacies to ensure compliance with this regulation. Documentation of compliance will be necessary otherwise, non-compliance will result in a recoupment of payments.

To view the CMS guidelines to follow to be considered compliant with the new tamper-resistant requirements, visit www.vtmedicaid.com under Information

************************************************************************ REIMBURSABLE/NON-REIMBURSABLE SERVICES (Page 37)

This supplement applies to all durable medical equipment (DME) including wheelchairs and other mobility devices, augmentative communication devices, prosthetics, orthotics and medical supplies, as described in Medicaid rules in sections M830, M840, M841, M842, and M843, available at local DCF offices.

Deleted: …as described in the Welfare Assistance Manual (WAM)

************************************************************************




ADAPTIVE WEIGHTED EATING UTENSILS (Page 38) Vermont Medicaid allows for the reimbursement of “Adaptive Weighted Eating Utensils” when medically necessary for individuals who have significant tremors that interfere with daily activities (i.e., ability to feed self).

These utensils must be ordered by a physician, must be medically necessary, supplied by a DME/Pharmacy or DME vendor, and billed using non-specific HCPCS code A9999. Only one of each type of utensil is allowed. The billing/supplying provider must submit an invoice with the claim in order to be reimbursed.

************************************************************************ VENTRICULAR ASSIST DEVICES (Page 45) Vermont Medicaid’s coverage of Ventricular Assist Devices is based on the CMS National Coverage Determination 20.9, entitled “NCD for Artificial Hearts and Related Devices”. Hospital and physician providers are referred to the current CPT and HCPCS manuals for proper coding.

************************************************************************


UB-04 SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/1/2012 – 6-10-2009

*Please note: -Sections below containing text in red font are additions to current policy. Previous verbiage will be noted, when applicable). -Section headings below in red font are new sections

**********************************************************************************

SPENDDOWN (page 17)

5. Enter the spend down amount on the UB04 Medicare Attachment Summary Form (MASF) for Medicare crossover claim types: X and W.

a. If no Other Insurance payment, check box for NO (6b) on MASF; the provider is to enter the spend down amount in the other insurance field on the MASF.

b. If there is an Other Insurance payment, check box for YES (6a) on MASF; the provider is to enter the total combined amount of the other insurance payment and the spend down in the other insurance field (6c) on the MASF.

Added: above section

**********************************************************************************

7/1/2012

CONCURRENT REVIEW FOR ADMISSIONS AT VERMONT AND IN-NETWORK BORDER HOSPITALS (page 8)

Effective for dates of service July 1, 2012 and after, all Vermont in-state hospitals and in-network border hospitals will be required to notify the Department of Vermont Health Access Clinical Unit of all inpatient stays at time of admission or by the next business day. This requirement does not apply to psychiatric unit and psychiatric hospital admissions. In addition, notification of patient discharge is required. The admitting/discharging facility may fax admission notification in the form of a daily census sheet or a utilization face sheet. The following information must be supplied: date of admission, patient name, DOB, beneficiary Medicaid ID #, admitting diagnosis, admitting status and admitting provider. The Inpatient Concurrent Review Procedures are available at dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

Prior Authorization is required if the patient stay is to exceed 13 days. The Admission Notification Form must be completed and submitted to the Clinical Unit to request authorization by day 13 of the inpatient stay. Failure to get a PA for an admission that exceeds 13 days will result in a denial of the claim. Forms are available at dvha.vermont.gov/for-providers/forms-1.

Admission/discharge notifications, prior authorization requests and all required clinical information can be faxed to the Clinical Unit at (802) 879-5963.


**********************************************************************************

HOSPITAL INPATIENT BILLING (page 21)

45. SERVICE DATE* Enter the ‘FROM’ date of the span of consecutive service dates being billed.


Deleted: the asterisk*, this is not a required field

**********************************************************************************

6/1/2012

CARDIAC REHABILITATION (page 7)

Cardiac rehabilitation is billable under revenue code 943. One unit is equal to one day regardless of the number of encounters. There is a limit of 36 units within 12 weeks.

Effective for date of service May 16, 2012 and thereafter, cardiac rehabilitation is limited to 36 sessions within a 36 week timeframe. Additional sessions may be approved by the DVHA Clinical Unit when the claim includes the appropriate notes and meets the required criteria. The maximum allowed number of additional sessions eligible for consideration is 72. Deleted: strikethrough text


**********************************************************************************

HOSPICE (page 26)

Vermont Medicaid reimburses for hospice services provided to patients in nursing homes. Under federal regulations, hospice providers who contract with nursing homes to provide services become responsible for management of the patient’s care and billing for all services, including the room and board normally paid to the nursing home. The revenue code 659 should be used for these hospice services and the name of the nursing home should be entered in field locator 80. Vermont Medicaid pays the hospice a rate which is equal to 95% of the nursing home’s established per diem rate, and the hospice in turn, pays the nursing home.

The date of death is not eligible for reimbursement from Vermont Medicaid.


**********************************************************************************

BENEFICIARIES IN HEALTH CARE INSTITUTIONS (page 37)

Payment will not be made for durable medical equipment and supplies ordered by a physician when the beneficiary is an inpatient in a health care institution, specifically a general or psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR). In these cases, the all-inclusive, per diem payment made to these facilities includes the equipment and supplies used by the patients.

The only exception is that payment will be made for a seating system, including required accessories, for an individual residing in a long-term care facility when the system is prescribed by a registered physical or occupational therapist trained in rehabilitative equipment and the system is so unique to the individual that it would not be useful to other nursing home residents. Cushions which are not integral to the seating system are not covered by this exception.

Payment for orthotics and prosthetics, including ostomy supplies and elastic stockings, may be made to the DME vendor when furnished to beneficiaries in residential facilities other than health care facilities (including nursing homes). The doctor and vendor must keep a medical necessity form and/or order, completed by the physician, and/or other appropriate documentation in the patient record.


**********************************************************************************

SECTION 5 CHOICES FOR CAREENHANCED RESIDENTIAL CARE (ERC)/Nursing Facilities Home Based Waiver (HBW) (page 44)


18-28. CONDITONS CODES Enter code to identify if condition is related to the following (*PSRO code is mandatory):

02-Conditon is Employment Related A1-EPSDT Related Services A4-Family Planning Related Services

Deleted: * (this is not a required field)

**********************************************************************************

5/1/2012 BORDER HOSPITALS (page 7)

Border hospitals are subject to the same Vermont Medicaid policy as are those located within the geographical confines of the state of Vermont. Their physicians must be enrolled with Vermont Medicaid. Out-of-state hospitals not designated as a Border Hospital must bill using Vermont Medicaid Provider ID # 0009999 the attending provider’s NPI number in field locator 76, if the attending providers are not enrolled with Vermont Medicaid. Please refer to the billing instructions at the end of this manual. For purposes of Vermont Medicaid reimbursement, the following hospitals are designated as “border hospitals”:

Deleted strikethrough text


**********************************************************************************

INPATIENT CLAIMS: MEDICARE PART A EXHAUSTS OR BEGINS DURING THE INPATIENT STAY (page 10)

1. The inpatient claim for the entire stay should be billed to Vermont Medicaid with “Medicare benefits exhausted or began on mm/dd/yy” indicated in field locator 80 on the UB.

2. Add together the Medicare B payment, the Medicare B contractual adjustment, and the Vermont Medicaid crossover payment. Indicate this total amount in field locator 54a on the UB.

3. Attach both the part A and B EOBs. On part A EOMB, write “Medicare benefits exhausted or began on mm/dd/yy”. The charges will not match on part B EOB. Sign and date part A EOMB.

Added: red text to the above section

If an inpatient claim is submitted to Medicare as primary payer is denied by Medicare because the patient’s Medicare covered benefits are exhausted, DVHA will pay the claim based on DRG Payment methodologies for the patient’s Medicaid covered services.

If a patient becomes Medicare eligible during an inpatient stay, Medicare will pay Medicare covered days as the primary payer. DVHA will pay for the Medicaid covered days as a separated DRG payment for the patient’s Medicaid covered services and DVHA will pay the coinsurance and deductible for the Medicare covered days.

Replaced the below text with the above red text If a patient exhausts their Medicare coverage during an inpatient stay, DVHA will pay the coinsurance and deductible for the Medicare-covered days and a separate DRG payment for the days where Medicaid is primary payer. The DRG payment will be prorated based on the number of Medicaid-covered to total days on the claim. **********************************************************************************

REIMBURSEMENT (page 16)


DRG Hospital Reimbursement-Vermont Medicaid Ineligibility: With the DRG reimbursement methodology in effect, any claims for beneficiaries who become ineligible for Vermont Medicaid during the duration of an inpatient stay must be billed to any TPL provider prior to billing Medicaid/HPES in its entirety. HPES will prorate these claims based on beneficiary eligibility and partially reimburse for the days the beneficiary was eligible for Vermont Medicaid.

Added: red text to the above section **********************************************************************************

BENEFICIARY PLACEMENT LEVELS (RPL) (page 50)

The VHAP benefit package includes a Skilled Nursing Facility (SNF) stay which is limited to 30 days per episode and 60 days per calendar year. This is an acute care benefit not a Long Term Care (LTC) benefit. This means the Choices for Care (CFC) LTC Medicaid application is no longer required for VHAP recipients accessing their SNF benefit. Admission of a VHAP recipient to a SNF is based on a physician’s order for SNF services with documentation of medical necessity for the treatment of illness or injury; the admitting diagnosis must support all treatment and therapies ordered and indicate that the service cannot be provided at a lower level of care. The SNF should communicate with the recipient and have them apply to DCF/ESD for CFC LTC Medicaid coverage for a stay greater than 30 days per episode or if the recipient is near their 60 day calendar year limit.

Added: red text to the above section **********************************************************************************

4/16/2012

OBSERVATION ROOMS (page 15)

Effective with the implementation of Outpatient Perspective Payment System (OPPS) 5/1/2008, Vermont Medicaid is packaging observation services with OPPS primary procedures. There are no exceptions for certain conditions as there are in Medicare. Charges for observation however will be included in the determination of whether or not the claim is eligible for an outlier payment.

Alternatively, Vermont Medicaid will pay for observation separately when there is NO primary procedure. Vermont Medicaid will pay the observation line on a claim using the hospital’s CCR; provided that the G0378 HCPCS appears on the labor room or observation room revenue code detail line and the number of hours in observation is indicated in the units field. The DVHA will pay the lesser of the billed amount times the hospital specific Cost to Charge Ratio (CCR), or $1,500. The DVHA will pay up to 24 hours of observation per stay at $35.00 per hour with a maximum reimbursement benefit of $840.00 per claim. Lab details as well as other CPT/HCPCS for which there is a separate OPPS fee assigned but are not designated as primary procedures in the OPPS will be paid separately. Deleted: the strikethrough text Added: red text to section **********************************************************************************

SECTION 1.1 HOSPITAL INPATIENT BILLING INSTRUCTIONS (page 19)

FIELD LOCATORS REQUIRED INFORMATION

17. STAT*

05-Discharged/Transferred to another Type of Institution (e.g. Hospice, Rehab Facility) Designated Cancer Center or Children's Hospital


Deleted: the strikethrough text Added: red text to section **********************************************************************************

4/1/2012 BORDER HOSPITALS (page 7)

Dartmouth Hitchcock Medical Center Lebanon, NH

Deleted: Mary Hitchcock Memorial Hospital Lebanon, NH Added: above text to section

**********************************************************************************

RADIOLOGY (page 16))

See the CMS 1500 Manual


**********************************************************************************

3/1/2012 PRIOR AUTHORIZATION (PA) (page 15)

Prior-authorization request forms are available at dvha.vermont.gov/for-providers/forms-1 an include the Out-of-State Pre-Admission Request Form; Pre-Procedure Request Form; Out-of State-Urgent and Emergent Admissions; and Out-of-State Psychiatric Hospital Notification Form..

Added: above text to section

**********************************************************************************

2/1/2012 ATTENDING PHYSICIAN (page 7)

Deleted: or a non-participating

When billing Vermont Medicaid on the UB-04 claim form, the attending physician’s number or NPI (with Taxonomy code when applicable) must appear in field locator 76.

Deleted: number or

**********************************************************************************

PRESENT ON ADMISSION (POA) - Inpatient Admissions (page 15)

The present on admission indicator (POA) will be required for all inpatient admissions. Vermont Medicaid will follow Medicare’s guidelines. The indicator options are: Y (Yes), N (No), U (Unknown), W (Not Applicable). If exempt from POA reporting leave the field blank. The POA indicator is the eighth digit and is required on all diagnoses codes listed on the UB 04 (principal field 67 and secondary field 67 A through Q). This is not required for the admit diagnosis (69). For electronic claims using the 837 Institutional, submit the POA indicator in HI01-9 of each appropriate HI segment. POA is always required first, followed by the principal diagnosis. The last secondary diagnosis indicator is followed by the letter Z to indicate the end of the data element. e.g., POAYNUW1YZ

A list of diagnosis codes exempt from requiring the POA indicator can be located at https://vtmedicaid.com/Information/whatsnew.html.

http://ovha.vermont.gov/for-providers/forms-1�

https://vtmedicaid.com/Information/whatsnew.html�


Added: above text

Deleted: The indicator options are: Y (diagnosis was present at time of the admission), N (diagnosis was not present at time of admission), U (documentation was insufficient to determine if present at time of admission), W (clinically undetermined), 1 (exempt from POA reporting).

Deleted: For electronic claims using the 837 institutional, submit the POA indicator in segment K3 in the 2300 loop, data element K301.

**********************************************************************************

1/1/2012 OUT-OF-STATE INPATIENT CARE (page 8)

OUT-OF-STATE URGENT/EMERGENT INPATIENT HOSPITAL ADMISSIONS

Replaced: section title with above red text

All out-of state-hospitals are required to notify the DVHA Clinical Unit of the pending discharge of a Vermont Medicaid beneficiary.

Added: above text

**********************************************************************************

OUT-OF-STATE ELECTIVE INPATIENT HOSPITAL ADMISSIONS (page 9)

All elective inpatient admissions require prior authorization from the DVHA Clinical Unit (excluding designated border hospitals) prior to the admission date. The admitting facility must complete and fax a Vermont Medicaid Out-of-State Preadmission Request Form and forward clinical documentation along with an explanation of why this care cannot be performed within the State of Vermont to (802) 879-5963. It is recommended that prior authorization be requested as early as possible but no less than 3 business days prior to the planned date of admission.

For further information and form access, please see the Out-of-State Admission Guidelines located at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

Added: new section title

**********************************************************************************

9/1/2011

INPATIENT CLAIMS: MEDICARE PRIMARY BUT MEDICAID ELIGIBILITY TERMED DURING STAY (page 12) When a Vermont Medicaid beneficiary has Medicare A but their Medicaid is termed during the stay, providers are instructed to bill as follows:

1. Bill part A charges to Medicare

2. The inpatient claim for the entire stay should be billed to Vermont Medicaid.

3. If the patient is eligible for the first day of service the Medicare A deductible will be paid. Complete the Medicare Attachment Summary. This claim can just be submitted directly to HP Enterprise Services.

4. If the patient is eligible with Vermont Medicaid for co-insurance days, you must attach the Medicare A EOB. On the Part A EOB write Medicare co-insurance start date is mm/dd/yy, write the co-insurance due and sign and date the part A EOB.

http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines�


5. Submit your claim and all attachments to your Vermont Medicaid Provider Representative. (See www.vtmedicaid.com under Information/Provider Representative Map).

Added: red text

********************************************************************************** HOLD BED (page 53) Claim Note section: The information in the notes segment must state: CERT FORM and to and from dates the facility was at maximum licensed occupancy. Electronic claims submitted without this information will be denied.

Added: red text

**********************************************************************************

8/1/2011

FACTOR HCPCS CODES (page 9)

Factor HCPCS Codes are typically submitted through the pharmacy benefit (except in cases of emergency). Claims for services billed through the medical benefit require notes be included. All claims submitted for emergency room services are exempt from this requirement.

Added: red text

**********************************************************************************

SECTION 3 HOSPICE ADULT DAY SERVICES BILLING INSTRUCTIONS (page 33)

Deleted: The word Hospice from section name

**********************************************************************************

PATIENT SHARE (page 53)

Patient share amounts are deducted from the first claim of the month when a beneficiary is still a patient. When the patient is discharged prior to months end, providers are required to adjust & recoup all claims paid for the month of discharge and resubmit one claim for the entire month's service, using the appropriate patient status code. The claim will then be processed and reimbursed without the patient share deduction.

Added: red text

**********************************************************************************

7/1/2011 PRESENT ON ADMISSION (POA) - Inpatient Admissions (page 16)

A list of diagnosis codes exempt from requiring the POA indicator can be located at https://vtmedicaid.com/Information/whatsnew.html.

Added: Sentence to section

**********************************************************************************

SECTION 2.1 (page 29)

HOME HEALTH AGENCY & HOSPICE SERVICES-GENERAL BILLING INSTRUCTIONS

Added: Red text

**********************************************************************************


https://vtmedicaid.com/Information/whatsnew.html�


5/4/2011 OUT-OF-STATE INPATIENT CARE (page 9)

All out-of-state urgent/emergency inpatient hospital admissions (excluding designated border hospitals) require notification be made to the DVHA Clinical Unit within 24 hours or the next business day of the admission. Notification can be made by faxing a completed Vermont Medicaid Admission Notification Form for Out-of-State Hospitals Urgent and Emergent Admissions to the DVHA at (802) 879-5963. Please include all clinical documentation. Concurrent review will begin at the time of notification and will continue through the course of the inpatient hospital stay. Failure to notify the DVHA Clinical Unit will result in a retrospective review of the inpatient hospital admission to validate the quality of care, medical necessity, clinical coding, appropriateness of place of service and evaluation of length of stay associated with care. Results of the retrospective review will be utilized to assess refund requests for services that were determined to be inappropriate or not medically necessary.

All elective inpatient admissions require prior authorization from the DVHA Clinical Unit (excluding designated border hospitals) prior to the admission date. The admitting facility must complete and fax a Vermont Medicaid Out-of-State Preadmission Request Form and forward clinical documentation along with an explanation of why this care cannot be performed within the State of Vermont to (802) 879-5963. It is recommended that prior authorization be requested as early as possible but no less than 3 business days prior to the planned date of admission.

For further information and form access, please see the Out-of-State Admission Guidelines located at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

All out-of state-hospitals are required to notify the DVHA Clinical Unit of the pending discharge of a Vermont Medicaid beneficiary.

Added: Red text

Deleted: below text

Elective out-of-state inpatient care is reimbursable only with prior authorization. If the type of admission on an out-of-state claim is emergent or urgent, prior authorization is not required. These claims are subject to retrospective review. See also Border Hospitals.

Preadmission Review: A preadmission review by the DVHA is required for many types of elective hospital admissions.

Emergency Care; Out-of-State: Inpatient hospital care due to an emergency is reimbursable out-of-state.

**********************************************************************************

4/1/2011 INPATIENT CLAIMS: NO MEDICARE PART A; HAS MEDICARE B COVERAGE (page 9)

Note the Provider Liable amount in field locator 54c (prior payments), with payer names of “VT Medicaid” in field locator 50c. Not the Provider Liable amounts in field locator 80 (example: Provider Liable for Part A is $XXX, for Part B is $XXX).

Deleted: above text

Added: Do not indicate Provider liable charges in field locator 54 of the UB-04 Claim Form. **********************************************************************************

3/1/2011

http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines�


OBSERVATION ROOMS (page 13) Vermont Medicaid will pay the observation line on the claim using the hospital’s CCR, provided that the G0378 HCPCS appears on the labor room or observation room revenue code detail line and the number of hours in observation appears in the units field. The DVHA will pay the lesser of the billed amount times the hospital specific Cost to Charge Ratio (CCR), or $1,500.

Added: Red text

**********************************************************************************

TIMELY FILING (page 16) Timely filing limit for inpatient claims is 180 days from the date of discharge. Please see the Provider Manual for additional timely filing information at www.vtmedicaid.com/Downloads/manuals.html Added: section

**********************************************************************************

2/1/2011 CLAIM SUBMISSION (page 7) Submit all paper claim requests to: HP Enterprise Services, PO Box 999, Williston, VT 05495-0888

Added: section

**********************************************************************************

INPATIENT MEDICALLY MANAGED DETOXIFICATION (page 10) Beginning March 1, 2011 the Department of Vermont Health Access will implement concurrent review and authorization of all inpatient medically managed detoxification services provided on a psychiatric floor or in a psychiatric facility. All emergent and urgent admissions will require notification to the DVHA within 24 hours or the next business day of admission and all elective admissions will require notification prior to admission. To notify DVHA of an admission and to begin the concurrent review process please call, (802)879-8232.

Added: section

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1/1/2011 FIELD LOCATOR (page 18)

17. STAT* 62-Transfer to Rehab Facility, including Distinct part rehab facility. 65-Transfer to a Psychiatric Hospital, including distinct part psych unit.

Added: red text

**********************************************************************************

12/01/2010 TRANSFER CASES (page 16) Transfer cases are defined as patients who initiate an inpatient stay in one hospital and are discharged/admitted from one acute care facility to another in the same day.

Deleted text: in the same day



**********************************************************************************

SECTION 5.1 CHOICES FOR CARE

NURSING FACILITIES BILLING INSTRUCTIONS

DME IN HEALTHCARE INSTITUTIONS (page 49) With one exception, payment will not be made for DME and supplies ordered by a physician when the beneficiary is an inpatient in a health care institution, specifically a general or psychiatric hospital, nursing facility, or intermediate care facility for the mentally retarded (ICF-MR). In these cases, the all-inclusive payment made to these facilities includes the equipment and supplies used by the beneficiaries.

The one exception is that payment will be made for a seating system, including required accessories, for an individual residing in a long-term care facility when the seating system is prescribed by a masters or doctoral level physical or occupational therapist trained in rehabilitative equipment and is so unique to the individual that it would not be useful to other nursing home residents. Cushions not integral to the seating system are not covered by this exception.

Payment for orthotics and prosthetics, including ostomy supplies and elastic stockings, may be made to the DME vendor when furnished to beneficiaries in residential facilities, including nursing homes. The doctor and vendor must keep a medical necessity form and/or order, completed by the physician, and/or other documentation of medical need in the beneficiary’s record.

Added: red text

**********************************************************************************

10/01/2010 NEWBORN ID NUMBER (page 13) 60-Mother’s Vermont ID Number 80-Write “Billing for baby under mother’s ID number”

Replaced: SSN number with ID number.

Deleted: all reference to a temporary ID number

********************************************************************************** FIELD LOCATOR – All Billing Instructions (pages17,21,28,32,37,41,45,52)

60. MEMBERS ID*

Added: Field Locator added to all billing instructions

********************************************************************************* FIELD LOCATOR – All Billing Instructions (pages17,21,28,32,37,41,45,52)

8a. PATIENT’S ID #* Enter patient’s Vermont Medicaid ID #.

Deleted: Field Locator from all billing instructions

********************************************************************************* HOLD BED (page 50) Claim Note section: The information in the notes segment must state: CERT FORM and the dates the facility was at maximum licensed occupancy. Electronic claims submitted without this information will be denied.


Providers submitting a Hold Bed claim on paper, are required to include an Occupancy Certification Form stating that the nursing home would otherwise be at its maximum licensed occupancy. Paper claims submitted without the Occupancy Certification Form will be denied. Added red text Changed: HOLD BEDS TO HOLD BED

*********************************************************************************

09/1/2010 FIELD LOCATOR – All Billing Instructions (pages17,21,28,32,37,41,45,52)

8a. PATIENT’S ID #* Enter patient’s Vermont Medicaid ID #.

Added: asterisks(Field Locator 8a. is now required for all billing.)

*********************************************************************************

MEDICARE CROSSOVER CLAIMS (page 11) A Vermont Medicaid recipient may be eligible for both Medicaid and Medicare. When dual eligibility exists, Medicare must be billed first. Vermont Medicaid is the payer of last resort. Vermont Medicaid will pay co-insurance and deductible, minus any applicable co-payment amounts on institutional crossovers.

Hospitals: For in-state and border hospitals, claims submitted to the Medicare carrier will crossover automatically to Vermont Medicaid for payment. Medicaid eligibility information must be clearly indicated on the Medicare claim submitted. If you do not receive Medicaid payment within 30 days of the Medicare payment date, or if you are an out-of-state (except New Hampshire) who has billed and received payment from your regional Medicare carrier for services to Vermont residents who are eligible for both Medicare and Vermont Medicaid, submit the crossover claim to HP as follows:

- Send an electronic Medicare Crossover Claim or Send a copy of the Medicaid claim with a copy of the Medicare summary form.

- Supplemental insurance payments should be entered in field locator 54.

- If a copy of the Medicare claim is not available, you may complete a UB-04 claim form and attach a copy of the Medicare summary form, or attach documentation that Medicare does not cover the service to a claim filled out following Vermont Medicaid rules.

- The Medicare payment date must appear on the Medicare summary form.

When a service is denied by Medicare and is covered by Vermont Medicaid, submit a Medicaid claim completed to Vermont Medicaid specifications within the following guidelines:

- To submit third party liability denials electronically, see the Provider Manual section 1.3.12 Third Party Liability (TPL)/Other Insurance (OI)

- Attach the remittance document from Medicare or a copy of the blanket denial showing that Medicare does not cover the service

- Send to HP within two years of the date of service on the Medicare summary form.

Added: red text

*********************************************************************************

07/28/2010

Replaced: The Office of Vermont Health Access (OVHA) with the Department of Vermont Health Access (DVHA), throughout supplement.


********************************************************************************* SECTION 2.1

HOME HEALTH AGENCY SERVICES-GENERAL BILLING INSTRUCTIONS (page 28)

13. ADMISSION HOUR* Enter the hour in which patient was admitted

14. ADMISSION TYPE* Enter the code indicating the priority of the admission:

1-Emergency 2-Urgent 3-Elective 4-Nursery

Removed: asterisk from Field Locator 13 & 14. These fields are not required.

**********************************************************************************

05/6/2010 PRESENT ON ADMISSION (POA) - Inpatient Admissions (page 13) Effective May 16, 2010 the present on admission indicator (POA) will be required for all inpatient admissions. Vermont Medicaid will follow Medicare’s guidelines. The indicator options are: Y (diagnosis was present at time of the admission), N (diagnosis was not present at time of admission) U (documentation was insufficient to determine if present at time of admission), W (clinically undetermined), 1 (exempt from POA reporting). The POA indicator is the eighth digit and is required on all diagnoses codes listed on the UB 04 (principal field 67 and secondary field 67 A through Q). This is not required for the admit diagnosis (69). For electronic claims using the 837 institutional, submit the POA indicator in segment K3 in the 2300 loop, data element K301. POA is always required first, followed by the principal diagnosis. The last secondary diagnosis indicator is followed by the letter Z to indicate the end of the data element. e.g.: POAYNUW1YZ

Added: section

**********************************************************************************

HOSPITAL INPATIENT BILLING – FIELD LOCATOR (page 22)

67. PRINCIPAL DIAGNOSES CODE* Enter the primary diagnosis code. Use the POA*(see page 13 for billing instructions) appropriate ICD-9-CM code.

67 a-q. OTHER DIAGNOSES CODES Enter the appropriate ICD-9-CM codes for POA*(see page 13 for billing instructions) any condition other than primary, which requires supplementary treatment

Added: red text

**********************************************************************************

05/3/2010

MEDICARE CROSSOVER CLAIMS (page 10) If you do not receive Medicaid payment within six weeks of the Medicare payment dare, or if you are an out-of-state (except New Hampshire) who has billed and received payment from your regional Medicare carrier for services to Vermont residents who are eligible for both Medicare and Vermont Medicaid, submit the crossover claim to HP as follows.

Replaced: six weeks with 30 days


Replaced: EOMB with summary form

**********************************************************************************

HOSPITAL OUTPATIENT BILLING - FIELD LOCATOR (page 21)

17. DISCHARGE STATUS* Enter the appropriate discharge code

Added: new field locator & description

**********************************************************************************

FIELD LOCATOR 18-28. CONDITONS CODES* (page 17, 20, 28 & 32)

Deleted: A3-Ladies First

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INTERPRETER SERVICES (page 24)

Vermont Medicaid providers paying interpreter services for a beneficiary (who does not speak the same language as the provider or for sign language for an hearing impaired beneficiary), in person or over the phone, may bill using revenue code 940 with procedure code T1013 for every 15 minutes of service provided.

Added: section

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03/2010

CHOICES FOR CARE (moved from page 8 to page 5)

Added:

1. Enhanced Residential Care services include: personal care. Meal Preparation, Medication Management, Nursing Overview, Activities, 24-hour Supervision, Laundry/Housekeeping.

2. Long Term Care services include: Personal Care, Meals/Nutritional Services, 24-hour Skilled Nursing, Rehab & Therapy, Activities, 24-hour Supervision, Social Services, and Laundry/Housekeeping.

3. Home Based Waiver services include: Case Management, Personal Care, Respite or Companion Care, Adult Day Services, Personal Emergency Response Systems.

**********************************************************************************

ASSISTIVE COMMUNITY CARE SERVICES (page 5)

Added: Reimbursable services include: Case Management, Personal Care Services, Nursing Assessment & Routine Tasks, Medication Assistance, on-site Assistive Therapy and Restorative Nursing.

Deleted: All providers are reminded that billing may not be done in advance of any service to be performed or supplied.

**********************************************************************************

ABORTIONS (page 5)

Induced abortions are billable only with Physician Certification. There are two different payment sources for abortions.

1. Vermont Medicaid

Added: These abortion services will be billed to HP for all beneficiaries.


Deleted: These abortion services will be billed to HP for all Beneficiaries with the exception that inpatient services for VHA_-Limited beneficiaries will not be reimbursed.

Deleted: Payment for abortions performed when the mother’s life is in danger or when the pregnancy is a result of incest or rape will continue to be made by EDS and reported on the RA.

2. State Funds

Added: Abortions considered medically necessary are billable to HP upon completion of a Physician Certification Form OVHA 219B, but are paid by the Department for Children and Families (DCF) funding.

Deleted: Abortions considered medically necessary are billable to EDS with the completion of physician certification form OVHA 219B. Physicians who have billed for a “medically necessary” abortion will not find that claim on the Remittance Advice (RA). “Medically necessary abortions must be paid using state dollars only. This means that the payment for a “medically necessary abortion will be paid by a State check and will not be included on the RA with your other Medicaid claims.

**********************************************************************************

CHOICES FOR CARE: (page 8)

ENHANCED RESIDENTIAL CARE LONG TERM CARE HOME BASED WAIVER

Deleted: All providers are reminded that billing may not be done in advance of any service to be performed or supplied. Payment may be considered for the following Long-Term Care rendered to an eligible Vermont Medicaid beneficiary:

- Services provided in a non-Medicare Facility

- Services provided in a Medicare Participating Facility

Moved CHOICES FOR CARE to page 5

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INPATIENT/OUTPATIENT OVERLAP EXAMPLES (page 8)

Deleted: (3rd paragraph): your inpatient admission date will become the date that the patient was admitted as an outpatient.

**********************************************************************************

SECTION 1.1

HOSPITAL INPATIENT BILLING INSTRUCTIONS

Added: FIELD LOCATOR 21. STAT* Code 21–Discharge/Transferred to Court/Law Enforcement (page 17)

**********************************************************************************

RESPITE BILLING (page 24)

Only provider types of Aged/Disabled Waiver, with Waiver indicated as provider specialty, may bill for respite care. Providers billing for respite must select a type of bill from the following:

Page change: Topic was on page14, moved to page 24 under Home Health

**********************************************************************************


INTERIM CLAIMS; INTERIM INPATIENT CLAIMS (page 10)

Inpatient acute care hospitals that have a long term patient may bill interim claims in at least 60-days intervals. Subsequent bills must be in the electronic adjustment bill format. Each bill must include all applicable diagnoses and procedures. Indicate in the note field: long term inpatient stay greater than 60 days. Providers are instructed to bill as follows: 1. Type of bill 112 – interim bill-first claim, patient status 30 – still a patient. 2. Type of bill for subsequent claims will be 117 - electronic replacement claim. Patient status will be either patient status 30, or a discharged patient status code.

Also See Subacute Care.

Added topic

**********************************************************************************SAME-DAY STAYS (page 14)

One day stays are defined as patients who are admitted and discharged from the same acute care facility on the same calendar day.

- Example: Patient is admitted 5:00am on 12/4/07 and released 11:30pm on 12/4/07. This is a same-day stay.

- Example: Patient is admitted at 10:00pm on 12/4/07 and released at 7:00am on 12/5/07. This is not a same day stay.

These claims will be paid the lesser of the cost of the case or the DRG payment.

Added topic

**********************************************************************************

TRANSFER CASES (page 15)

Transfer cases are defined as patients who initiate an inpatient stay in one hospital and are discharged/admitted from one acute care facility to another in the same day.

- The receiving hospital will be paid under normal DRG payment logic.

- The transferring hospital will be paid the lesser of the cost of the case or the DRG payment (including any eligible outlier payment).

Added topic

**********************************************************************************

NDC (NATIONAL DRUG CODE) (page 11 & 21) NDC indicator N4 identifies NDC (page 11)

FIELD LOCATOR

43. NDC CODE* (page 21) Enter the NDC code of the drug that was dispensed. Use a “N4” indicator preceding the NDC to identify the information in FL 43 as an NDC.

Added red text

**********************************************************************************

HOSPITAL INPATIENT BILLING INSTRUCTIONS (page 17)


Field Locator - 4.Type of Bill 3. Frequency: removed : 5 - late charges; this code is to be used only when submitting charges that were not included on a previously filed claim.

**********************************************************************************

FIELD LOCATOR 47 – ALL BILLING INSTRUCTIONS (pages 19, 21, 29, 32, 38 42, 46, & 52)

47. TOTAL CHARGES* Enter the total charges pertaining to each revenue code billed for the current billing period. Add the total charges for all revenue codes being billed and enter at the bottom of column 47 in the total field. (detail line 23)

**********************************************************************************

(09/01/2009)

RESPITE BILLING (Page 14) Only provider types of Aged/Disabled Waiver, with Waiver indicated as provider specialty, may bill for respite care. Providers billing for respite must select a type of bill from the following:

1. Type of Facility 8-Hospice or Special Facility

2. Bill Classification 6-Respite

3. Frequency 1-Admit through discharge claim 2-Interim-first claim 3-Interim-continuity claim 4-Interim-last claim

For additional information, please refer to: http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-highest/policies-cfc-highest-manual.

Added Topic

**********************************************************************************

(06/10/2009)

ABORTIONS (Page 6) 2. State Funds

Abortions considered medically necessary are billable to HP with the completion of the physician certification form OVHA 219B…

Deleted: …are billable to HP and paid by the Administrative Services (OVHA, 103 South Main Street, Waterbury, VT 05671) with the completion of physician certification form PATH 219B)

**********************************************************************************

INPATIENT CLAIMS; NO MEDICARE PART A-HAS MEDICARE B COVERAGE (Page 10)

3. Submit your claim and all attachments to your Vermont Medicaid Provider Representative. (See www.vtmedicaid.com under Information/Provider Representative Map).

Deleted: 3. Write on EOB “No Medicare A”. The charges will not match, only billing ancillaries to Medicare B which will crossover to Vermont Medicaid. Sign and date the EOMB.

http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-highest/policies-cfc-highest-manual�

http://ddas.vermont.gov/ddas-policies/policies-cfc/policies-cfc-highest/policies-cfc-highest-manual�



**********************************************************************************

PRIOR AUTHORIZATION (Page 14) Prior authorization is required for certain surgical procedures. See the Prior Authorization Supplement for instructions on obtaining prior authorization for these services. For a complete list of codes that require PA, see the fee schedule at: www.vtmedicaid.com under Downloads/Manuals. The Pre-Admission Request Form and the Pre-Procedure Request Form are available for download at www.vtmedicaid.com under Downloads/Forms.

**********************************************************************************

REVENUE CODE AND DATE SPAN BILLING (Page 36) ACCS providers must bill revenue code 0098 assigned by the Department of Aging and Disabilities in field locator 42…

Deleted: ACCS providers must bill revenue code 0098 by the Department of Disabilities, Aging and Independent Living…




PA SUPPLEMENT DETAILED SUMMARY OF UPDATES 9/1/2012 – 7-14-2009

*Please note: -Sections below containing text in red font are additions to current policy. Previous verbiage will be noted, when applicable). -Section headings below in red font are new sections*

******************************************************************************

1.1 SERVICES AND ITEMS REQUIRING PRIOR AUTHORIZATION

2 SECTION 2 PRIOR AUTHORIZATION LISTING

Replaced: MedMetrics with Catamaran

******************************************************************************

8/14/2012

1.13 IN-STATE PSYCHIATRIC ADMISSION REQUESTS (page 9)

Beginning August 1, 2009, the DVHA implemented concurrent reviews of all in-state psychiatric inpatient admissions for Vermont Medicaid primary children and adolescents, and young adults ages 18 and up to the age of 22 (excluding beneficiaries enrolled in CRT) to the Brattleboro Retreat. All admissions will continue to require a screening by the local Community Mental Health Center prior to admission. The procedure for CRT admissions and concurrent review remains unchanged.

Deleted: above text and Replaced it with the below red text

1.14 IN-STATE & OUT-OF-STATE PSYCHIATRIC AND INPATIENT SERVICES

Effective August 13, 2012 the Department of Vermont Health Access (DVHA) in collaboration with the Department of Mental Health (DMH) will require authorization of all psychiatric and detoxification inpatient services for both in-state and out-of-state admissions. This includes all children and adults, including those enrolled in CRT. Admitting facilities must complete the Vermont Medicaid Admission Notification Form for Psychiatric Inpatient Services and fax it to the DVHA at 802-879-5963 within 24 hours or the next business day of an urgent or emergent admission. All individuals enrolled in CRT, children and adolescents will continue to require screening by a Community Mental Health Center prior to admission. Notification forms are posted on the DVHA website at http://dvha.vermont.gov/for-providers/forms-1.

******************************************************************************

7/1/2012

1.5.4 REHABILITATIVE THERAPY (page 6)

Beneficiaries under age 21 Effective July 1, 2012, prior authorization for outpatient therapies (PT, OT, ST) will change for Medicaid beneficiaries under age 21. The initial eight visits from the start of the beneficiary’s acute care episode/condition are allowed, per therapy discipline, before prior authorization is required. Providers must request prior authorization in advance of the 9th visit if additional therapy services are necessary. Providers are required to determine the first date of treatment at any outpatient facility, regardless of coverage source. It is the responsibility of the therapists to track therapy visit/service history.

Subsequent authorizations will be required at 4 month intervals, based on the start of care date.

This change does not apply to home health agencies.


Providers should refer to Medicaid Rule and Therapy Guidelines for additional information at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines Added: above text

******************************************************************************

1.12 OUT-OF-NETWORK ELECTIVE OUTPATIENT REFERRALS

Effective July 1, 2012, non-emergency (elective) out-of-state medical visits will require prior authorization from the DVHA Clinical Unit. Enrolled border hospitals are excluded from this requirement. In network referring providers must submit requests using the Out-of-state Elective Office Visit Request Form located at http://dvha.vermont.gov/for-providers/forms-1. Fax requests to 802-879-5963.

******************************************************************************

1.14 CONCURRENT REVIEW FOR ADMISSIONS AT VERMONT AND IN-NETWORK BORDER HOSPITALS (page 10)

Effective for dates of service July 1, 2012 and after, all Vermont in-state hospitals and in-network border hospitals will be required to notify the Department of Vermont Health Access Clinical Unit of all inpatient stays at time of admission or by the next business day. This requirement does not apply to psychiatric unit and psychiatric hospital admissions. In addition, notification of patient discharge is required. The admitting/discharging facility may fax admission notification in the form of a daily census sheet or a utilization face sheet. The following information must be supplied: date of admission, patient name, DOB, beneficiary Medicaid ID #, admitting diagnosis, admitting status and admitting provider. The Inpatient Concurrent Review Procedures are available at dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

Prior Authorization is required if the patient stay is to exceed 13 days. The Admission Notification Form must be completed and submitted to the Clinical Unit to request authorization by day 13 of the inpatient stay. Failure to get a PA for an admission that exceeds 13 days will result in a denial of the claim. Forms are available at dvha.vermont.gov/for-providers/forms-1.

Admission/discharge notifications, prior authorization requests and all required clinical information can be faxed to the Clinical Unit at (802) 879-5963.

Failure to notify the DVHA Clinical Unit will result in a retrospective review of the inpatient hospital admission to validate the quality of care, medical necessity, clinical coding, appropriateness of place of service and evaluation of length of stay associated with care. Results of the retrospective review will be utilized to assess refund requests for services that were determined to be inappropriate or not medically necessary.

Added: added red text

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1/1/2011 1.11 OUT-OF-STATE ELECTIVE INPATIENT HOSPITAL ADMISSIONS (page 9)

The hospital is required to notify the DVHA upon patient discharge.

Deleted: above text

******************************************************************************

12/1/2011


http://dvha.vermont.gov/for-providers/forms-1�


1.5.4 REHABILITATIVE THERAPY (page 6)

As of November 7, 2011, prior authorization for outpatient therapies (PT, OT, ST) will change for Medicaid beneficiaries under age 21. The initial eight visits from the start of the beneficiary’s acute care episode/condition are allowed, per therapy discipline, before prior authorization is required. Providers must request prior authorization in advance of the 8th visit if additional therapy services are necessary. Providers are required determine the first date of treatment at any outpatient facility, regardless of coverage source. It is the responsibility of the therapists to track therapy visit/service history.



Providers should refer to Medicaid Rule and Therapy Guidelines for additional clarification at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines

Deleted: above text

******************************************************************************

1.5.5 PRIOR AUTHORIZATION FOR PEDIATRIC BENEFICIARIES (page 6)

All medical reviews for therapies, including pediatric beneficiaries will be conducted by the DVHA. Request for therapy services for pediatric beneficiaries beyond the first four months of care, must be faxed to 802-879-5963 or may be mailed to: DVHA, Clinical Unit, 312 Hurricane Lane, Suite 201, Williston, VT 05495.

Added: Section back to manual

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11/1/2011 1.5.4 REHABILITATIVE THERAPY (page 6)

As of November 7, 2011, prior authorization for outpatient therapies (PT, OT, ST) will change for Medicaid beneficiaries under age 21. The initial eight visits from the start of the beneficiary’s acute care episode/condition are allowed, per therapy discipline, before prior authorization is required. Providers must request prior authorization in advance of the 8th visit if additional therapy services are necessary. Providers are required determine the first date of treatment at any outpatient facility, regardless of coverage source. It is the responsibility of the therapists to track therapy visit/service history.



Providers should refer to Medicaid Rule and Therapy Guidelines for additional clarification at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines


******************************************************************************

1.5.5 PRIOR AUTHORIZATION FOR PEDIATRIC BENEFICIARIES (page 6)

All medical reviews for therapies, including pediatric beneficiaries will be conducted by the DVHA. Request for therapy services for pediatric beneficiaries beyond the first four months of care, must be faxed to 802-879-5963 or may be mailed to: DVHA, Clinical Unit, 312 Hurricane Lane, Suite 201, Williston, VT 05495.

Deleted: Section

******************************************************************************




5/4/2011 1.11 OUT-OF-STATE ELECTIVE INPATIENT HOSPITAL ADMISSIONS

(Excluding Designated Border Hospitals) All elective inpatient admissions to out-of-state hospitals require prior authorization from the DVHA Clinical Unit prior to admission. The admitting facility must fax a completed Vermont Medicaid Out of State Preadmission Form located at http://dvha.vermont.gov/for-providers/clinical-coverage-guidelines , clinical documentation and an explanation as to why this care cannot be performed within the State of Vermont to (802) 879-5963. The prior authorization must be requested as early as possible and no less than 3 business days prior to the planned admission.

The hospital is required to notify the DVHA upon patient discharge.

Added: red text

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1.13 UNLISTED PROCEDURE CODES

All unlisted procedure codes (including urgent or emergent) require prior authorization from the DVHA clinical unit. In addition, notes must be attached indicating the usual and customary charge for the service to be performed.

Added: section

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2/1/2011 1.5.3 INPATIENT MEDICALLY MANAGED DETOXIFICATION (page 6) Beginning March 1, 2011 the Department of Vermont Health Access will implement concurrent review and authorization of all inpatient medically managed detoxification services provided on a psychiatric floor or in a psychiatric facility. All emergent and urgent admissions will require notification to the DVHA within 24 hours or the next business day of admission and all elective admissions will require notification prior to admission. To notify DVHA of an admission and to begin the concurrent review process, please call (802)879-8232.

Added: section

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1.9 OUT-OF-STATE PSYCHIATRIC ADMISSION REQUESTS (page 8) For adults, prior to admission, the referring physician should notify the DVHA Clinical Unit directly at: (802) 879-5903.

Deleted: (802) 879-5903 replaced with (802) 879-8232

******************************************************************************

12/7/2010 1.4.1 OTHER INSURANCE (OI) Vermont Medicaid is the payer of last resort. Providers must pursue and apply all third party payment resources prior to billing Vermont Medicaid (see Third Party Liability, Section 1.3 of Provider Manual).

The following procedures are required for DVHA authorization requests when the primary insurer has reviewed and denied a claim request for an item or service:




-If the code/service does not require authorization from Vermont Medicaid, then the provider can bill Medicaid directly with a copy of the primary insurer’s denial attached.

OI Denial for Not Medically Necessary - The provider and/or beneficiary is required to pursue all levels of reconsideration and appeals with the primary insurer. If the request remains denied by the primary insurer, the provider and/or beneficiary is required to seek review by the BISHCA if the cost of the item or service exceeds $100. If the denial stands, then the provider may submit the request to the DVHA with copies of all of the original documentation, the denials from the primary insurer and the BISHCA’s support of the denial. The provider should not submit any additional documentation than what was reviewed by the primary insurer.

-If the code/service does not require authorization from Vermont Medicaid, then the provider can bill Medicaid directly, with copies of the primary insurer’s denials (original and appeals) and the BISHCA’s support of the denial attached.


The DVHA will reject a request if there is reason to believe that the OI received incorrect or

incomplete information from the provider and based its decision on that incorrect or incomplete information. Providers must determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by both OI or Medicare and the DVHA.

Deleted: See Provider Manual

******************************************************************************

1.5.3 CONVERSION FROM OTHER INSURANCE FOR PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH THERAPY (PT, OT, ST) EXCEPTION

Payment for PT/OT/ST requires PA for services extending beyond 4 months from the original date of service. If the DVHA is or becomes the primary insurer in the first three months, authorization must be approved prior to any service provided beyond four months. If the DVHA is not the primary insurer at any time in the first three months and becomes primary afterwards, authorization must be approved within thirty days of the DVHA becoming the primary insurer for continuing care beyond four months.

When other insurance does not cover a service due to exhaustion of benefits or non-covered services, Vermont Medicaid becomes the primary insurer and PA rules apply, as necessary. Providers have a 30-day window to secure PA. PA is not required in that 30-day window until the PA decision is rendered.

Primary benefits must be used before Vermont Medicaid, and all rules for obtaining services must be followed for the primary carrier. If the rules are not followed, Vermont Medicaid will deny the charges. It is the responsibility of the provider to provide proof that other insurance is not considered primary for the charges submitted, in order for those charges to be processed as primary with Vermont Medicaid. See section 1.4.1.

Deleted: section


******************************************************************************

1.5.4 REHABILITATIVE THERAPY Provision of PT/OT/ST beyond four months requires PA. PA will be granted when the need for continuing care is shown. The need must meet the requirements of Medicaid Rule 7102.2. Authorizations may be approved for any period beyond four months and up to 12 months from the original start date.

Provision of PT/OT/ST beyond the 12-month limit requires PA, and will be granted when the following criteria are met (Medicaid Rule 7401.4):

The service may not be reasonably provided by the patient’s support person(s), and one of the following criteria:

· The patient undergoes another acute care episode or injury, or

· The patient experiences increased loss of function, or

· Deterioration of the patient’s condition is imminent and predictable.

Deleted: text and replaced with red text specified below.

1.5.4 REHABILITATIVE THERAPY

Effective July 1, 2010, Physical, Occupational, and Speech Therapy outpatient services for adults (Medicaid and VHAP) are limited to 30 combined visits per calendar year. Prior authorization for therapy visits beyond 30 combined visits in a calendar year can be requested for beneficiaries with the following diagnoses: spinal cord injury, traumatic brain injury, stroke, amputation, or severe burn.

Changing programs or eligibility status within the calendar year does not reset the number of available visits. See Frequently Asked Questions at dvha.vermont.gov/for-providers/clinical-coverage-guidelines.

Limitations and prior authorization requirements do not apply when Medicare is the primary payer.

The limit does not apply to services provided in inpatient facilities or by home health agencies; inpatient facilities and home health agencies should follow the rules and processes currently in place.

******************************************************************************

1.5.5 PRIOR AUTHORIZATION FOR PEDIATRIC BENEFICIARIES

Deleted: year replaced with 4 months

Deleted: Therapists should use the Medicaid Request for Extension of Rehabilitation Therapy Services form. Be sure to include the “from” and “to” dates that constitute the beginning and end of the authorization period in the space available in column 1 of the form. Medical necessity determination for children will continue to use the information on EPSDT provided in regulations (Medicaid Rule 4100, 7103 & 7410).

Inserted: Therapists should use the Medicaid Request for Extension of Rehabilitation Therapy Services form. Be sure to include the original start of care date by any facility or provider, for the condition listed.

******************************************************************************

11/1/2010

1.4 PRIOR AUTHORIZATION REQUIREMENTS (page 4) The DVHA PA criteria and regulations can be found in Medicaid Rule 7102. These rules and procedures govern PAs performed by the DVHA and its agents. DVHA rules are available online at dvha.vermont.gov/budget-legislative.

http://ovha.vermont.gov/budget-legislative�


PA is necessary if our eligibility system indicates that there is not other insurance coverage for the service or item. The DVHA PA requirements apply when the DVHA is known to be the primary payer for the service or item.

The DVHA Clinical Operations Unit enters prior authorizations with the exact procedure code(s) given by the requesting provider on the request form. In those instances when the procedure code to be billed does not exactly match the code requested/authorized, the provider must notify the Clinical Unit in writing prior to claim submission. Include the DVHA prior authorization number, the rationale for the code change and signature. Fax information to (802) 879-5963.

Added: red text to section

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08/27/2010

SECTION 2 (page 10)

PRIOR AUTHORIZATION LISTING

The services and items that require prior authorization are listed in the Fee Schedule posted at: dvha.vermont.gov/for-providers. Some DME items are subject to quantity limits that can be extended with PA. A listing of the codes that have quantity limits and their limits is located in the DME Fee Schedule. Effective September 1, 2010, select outpatient elective diagnostic imaging procedures require prior authorization; please see the Diagnostic Imaging Program Guidelines & list of radiology CPT codes requiring prior authorization located at vtmedicaid.com/Downloads/manuals.html.

Contact numbers for the reviewers:

DVHA Clinical Unit (802) 879-5903 Fax (802) 879-5963 Dental (802) 879-5903 VDH-MH (802) 241-2604

Pharmacy, Point of Sale Medmetrics Clinical Call Center (800) 918-7549 Medmetrics Fax (866) 767-2649

Elective Diagnostic Outpatient High Tech Imaging MedSolutions Customer Service (888) 693-3211, 8a.m. to 9 p.m., M-F MedSolutions Fax (888)693-3210 Internet PA Requests www.medsolutionsonline.com

Fax forms can be obtained at www.medsolutionsonline.com or by calling MedSolutions Customer Service. Diagnostic Imaging Program Guidelines and a complete list of CPT codes requiring prior authorization can be accessed at vtmedicaid.com/Downloads/manuals.html.

Added red text **************************************************************************************

07/26/2010 Replaced: The Office of Vermont Health Access (OVHA) with the Department of Vermont Health Access (DVHA), throughout manual. **************************************************************************************

1.4 PRIOR AUTHORIZATION REQUIREMENTS (page 4) The DVHA PA requirements only apply when the DVHA is known to be the primary payer for the service or



http://www.medsolutionsonline.com/�

http://www.medsolutionsonline.com/�



item. If our system indicates that there is not other insurance coverage for this service or item, PA is necessary.

Deleted above text

PA is necessary if our eligibility system indicates that there is not other insurance coverage for the service or item. The DVHA PA requirements apply when the DVHA is known to be the primary payer for the service or item.

Added above red text **************************************************************************************

1.4.1 OTHER INSURANCE (OI) (page 5) 1.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim as “non-covered” or “benefits exhausted”, the provider does not need to appeal to that primary insurer before billing Medicaid. However, if the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request authorization from the DVHA in the regular manner (fax all standard documentation required for a clinical review) and include a copy of the other insurer’s (or Medicare’s) denial.

2.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim for other reasons (such as “not medically necessary”, “pre-existing condition” or “waiting period not met”), the provider must first appeal to the primary insurer. Only after all OI/Medicare appeals (through the Qualified Independent Contractor level and Banking Insurance, Securities & Health Care Administration (BISHCA) if eligible and available) are denied can the provider then request coverage by Vermont Medicaid. All documentation showing the original claim, appeal and denial must be attached. However, if the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request retroactive authorization from the DVHA in the regular manner (fax all standard documentation required for a clinical review) and include copies of the other insurer’s or Medicare’s denials and appeals.

In order for providers to determine whose rules will apply, it is imperative that providers understand how to find and interpret the information available. Providers can access this information via the Vermont Medicaid website (www.vtmedicaid.com) or the Voice Response System (VRS) 802 878-7871. Please see the Provider Manual for further information. Vermont Medicaid is the payer of last resort.

Deleted above text

1.4.1 OTHER INSURANCE (OI) Vermont Medicaid is the payer of last resort. Providers must pursue and apply all third party payment resources prior to billing Vermont Medicaid (see Third Party Liability, Section 1.3 of Provider Manual).

The following procedures are required for DVHA authorization requests when the primary insurer has reviewed and denied a claim request for an item or service:



-If the code/service does not require authorization from Vermont Medicaid, then the provider can bill Medicaid directly with a copy of the primary insurer’s denial attached.

OI Denial for Not Medically Necessary - The provider and/or beneficiary is required to pursue all levels of reconsideration and appeals with the primary insurer. If the request remains denied by the primary insurer,


the provider and/or beneficiary is required to seek review by the BISHCA if the cost of the item or service exceeds $100. If the denial stands, then the provider may submit the request to the DVHA with copies of all of the original documentation, the denials from the primary insurer and the BISHCA’s support of the denial. The provider should not submit any additional documentation than what was reviewed by the primary insurer.

-If the code/service does not require authorization from Vermont Medicaid, then the provider can bill Medicaid directly, with copies of the primary insurer’s denials (original and appeals) and the BISHCA’s support of the denial attached.


The DVHA will reject a request if there is reason to believe that the OI received incorrect or

incomplete information from the provider and based its decision on that incorrect or incomplete information. Providers must determine OI/Medicare benefits before rendering the service to minimize the risk of non-coverage by both OI or Medicare and the DVHA.


****************************************************************************** 05/24/2010

TABLE OF CONTENTS (page 3)

In order to assure that you have the most current version of this document, please refer to www.vtmedicaid.com. This is the site for the most current edition of the Provider Manual and its Supplements. If you do not have access to the internet, contact EDS Provider Services Help Desk at: 800-925-1706 or 802-878-7871.

Deleted above text

Added: The current Provider Manual and its Supplements can be accessed at www.vtmedicaid.com/downloads/manuals.html. HP Enterprise Services recommends that providers check the Vermont Medicaid website periodically, for updates, to assure the accuracy of the information being referenced. If you do not have internet access and need assistance, contact the HP Provider Services Help Desk at 800-925-1706 or 802 878-7871.

Medicaid/OVHA Rules are available on line at ovha.vermont.gov/for-providers.

****************************************************************************** 1.1 SERVICES AND ITEMS REQUIRING PRIOR AUTHORIZATION (page 4)

Some services and items require PA. A complete listing of the codes, with PA requirement is in the fee schedule and can be accessed on the OVHA’s website (ovha.vermont.gov/for-providersclaims-processing-1). All prescription drugs are reviewed by MedMetrics (see the Pharmacy section at ovha.vermont.gov/for providers).


****************************************************************************** 1.5 PRIOR AUTHORIZATION EXCEPTIONS (page 5)

Changed: Medicaid Rule from M106 to 7106


http://www.vtmedicaid.com/downloads/manuals.html�


****************************************************************************** 1.5.4 REHABILITATIVE THERAPY (page 7)

Changed: Medicaid Rule from M106.3 to 7102.2


****************************************************************************** 1.5.5 PRIOR AUTHORIZATION FOR PEDIATRIC BENEFICIARIES (page 7) Changed: Medicaid Rule from M100, M107 & M770 to 4100, 7103 & 7410

***************************************************************************** 1.7 PRIOR AUTHORIZATION RESPONSES (page 7)


***************************************************************************** 09/17/2009

1.10 OUT-OF-STATE URGENT/EMERGENT INPATIENT HOSPITAL ADMISSIONS (Excluding Designated Border Hospitals) All urgent and emergent inpatient admissions to out-of-state (OOS) hospitals require notification to the OVHA Clinical Unit of the admission within 24 hours or the next business day. Concurrent review will begin at the time of notification and throughout the course of the inpatient hospital stay. The admitting hospital must fax a completed Vermont Medicaid Admission Notification Form for Out of State Hospitals Form and clinical documentation to the OVHA at (802) 879-5963.

The hospital is required to notify the OVHA upon patient discharge.

1.11 OUT-OF-STATE ELECTIVE INPATIENT HOSPITAL ADMISSIONS (Excluding Designated Border Hospitals) All elective inpatient admissions to out-of-state hospitals require a prior authorization from the OVHA Clinical Unit before admission. The admitting facility must fax a completed Vermont Medicaid Out of State Preadmission Form and clinical documentation which must include an explanation of why this care cannot be performed within the State of Vermont to (802) 879-5963. The prior authorization must be requested as early as possible and no less than 3 business days prior to the planned admission.

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07/14/2009 SECTION 1.1 SERVICE AND ITEMS REQUIRING PRIOR AUTHORIZATION (Page 4)

Some services and items require PA. A complete listing of the codes can be accessed on the OVHA’s website (http://ovha.vermont.gov/for-providers). All prescription drugs are reviewed by Medmetrics.

Deleted: …and reviewers can be found in Section 2. In addition… …First Health Services Corp. See the Pharmacy Provider Manual for complete details

******************************************************************************

1.4 Prior Authorization Requirements (Page 4)

The OVHA prior authorization criteria in regulations can be found in Medicaid Rule M106.

Deleted: …section M106 of the Welfare Assistance Manual (WAM) Copies of the OVHA regulations are available at the OVHA website http://ovha.vermont.gov/for-providers.





See the Provider Manual for details on how to use the verification systems.

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1.4.1 OTHER INSURANCE (Page 5)

1.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim as “non-covered” or “benefits exhausted”, the provider does not need to appeal to that primary insurer before billing Medicaid. However, if the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request authorization from the OVHA in the regular manner (fax all standard documentation required for a clinical review) and include a copy of the other insurer’s (or Medicare’s) denial.

2.) When the Vermont Medicaid beneficiary’s primary insurer (including Medicare) denies a claim for other reasons (such as “not medically necessary”, “pre-existing condition” or “waiting period not met”), the provider must first appeal to the primary insurer. Only after all OI/Medicare appeals (through the Qualified Independent Contractor level and BISHCA if eligible and available) are denied can the provider then request coverage by Vermont Medicaid. All documentation showing the original and appeals’ denials must be attached. However, if the code/service requires prior authorization from Vermont Medicaid, then the provider will need to request retroactive authorization from the OVHA in the regular manner (fax all standard documentation required for a clinical review) and include copies of the other insurer’s or Medicare’s denials and appeals.

In order for providers to determine whose rules will apply, it is imperative that providers understand how to find and interpret the information available. Providers can access this information via the Vermont Medicaid website (www.vtmedicaid.com) or the Voice Response System (VRS). Please see the Provider Manual for further information. Vermont Medicaid is payor of last resort.

******************************************************************************

1.5 Prior Authorization Exceptions (Page 5)

Medicaid Rule M106 allows two general exceptions…

Deleted: WAM section…

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1.5.2 Immediate Need Exception (Page 5)

…the OVHA will provide normal reimbursement for a reasonable quantity of consumable items actually provided and/or the OVHA will provide normal reimbursement for the rental of such items in the minimum period for the service.

Deleted: thirty-day increments.

2. Authorization in advance does not have to occur if the service or item is rendered for immediately needed care as defined below. However, the request for PA must be faxed to the OVHA Clinical Unit the next business day…

Deleted: …prior notice of the order, or prescription, for the service or item is required to be considered timely. This may be accomplished by Fax or e-mail to the OVHA on a 7-day per week basis.

******************************************************************************

1.5.3 Conversion from Other Insurance for Physical Therapy, Occupational Therapy, Speech Therapy (PT/OT/ST) Exception (Page 6)

Payment for PT/OT/ST requires PA for services…


Deleted: Payment for physical therapy… In order for providers to determine whose rules will apply, it is imperative that you understand how to find and interpret the information available to you. When using the VRS (Malcolm) you will receive the following information: “The beneficiary has an insurance policy with (Other Insurance Company Name).” June, 2007 PA Supplement Page - 6 - If the insurance company name is on the list of the 50 most frequently used carrier names, the system speaks the recorded company name. If the insurance company name is not on the list, the system speaks the company code: “The beneficiary has an insurance policy with coverage type (10).” -or- “Carrier number is: (Two-digit carrier code (i.e. DZ), which is assigned to each different carrier and/or benefit plan) The system will speak five TPL segments and on the sixth segment the system will provide the user with the following options: Continue to receive carrier information Transfer to a PSU Help Desk representative In order to determine whether there is primary insurer for the services you are rendering, you will need note the Insurance coverage type and refer to the Third Party Liability Coverage Code Matrix, found in the Provider Manual, Section 1.3. You will find that each coverage code listed will also show services that would be considered eligible under this insurers plan. In the example above, insurance coverage type 10 covers outpatient and physician services. Because PT/OT/ST is normally covered as an outpatient or physician service, it would be logical to assume that this insurance is primary for these services. In another example, if the insurance coverage type is 09, the matrix indicates this type of insurance covers only pharmacy, so it would be logical to assume VT Medicaid is the primary insurer and that any guidelines associated in receiving services would need to be followed. Once you have determined that there is a primary insurer, you will need to gather the billing information in order to submit your charges. The Insurance Carrier codes (also found in the Provider Manual or on the HP website at: www.vtmedicaid.com) will allow you to look up information necessary to billing. In order for benefits to be payable under Vermont Medicaid, the primary insurers rules must be

followed, including requesting an extension of benefits, if applicable.

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1.5.4 Rehabilitative Therapy (Page 7)

...The need must meet the requirements of Medicaid Rule M106.3…

Deleted: WAM section…

Extension of services can be approved up to four additional months per request.

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1.5.5 Prior Authorization for Medicaid Pediatric Beneficiaries (Page 7)

Medical necessity determination for children will continue to use the information on EPSDT provided in regulations M100, M107 and M770.

Deleted: Effective August 1, 2003…

******************************************************************************


1.5.6 Required Documentation for Prior Authorization Requests (Page 7)

If a request for PA is denied and a provider has questions or needs additional information, contact the OVHA Clinical Unit.

Deleted: …Person whose name appears on the Notice of Decision.

The outside envelope or FAX cover sheet should be clearly marked as a PA Request. If a request for prior authorization is denied and a provider has questions or needs additional information, contact the person whose name appears on the PA Notice of Decision.

Deleted: If a notice of approval is received, providers may then submit a completed claim for payment, where the system matches PA information with claim information. If there are no additional attachments required, the claim may be submitted electronically.

…(the form received in the mail informing you of the decision).

******************************************************************************

1.5.7 Prior Authorization Responses (Page 7)

Under Medicaid Rule M106.5, the OVHA is obligated to make its review determinations within three working days of obtaining all necessary information. However… Written confirmation will be sent within 24 hours… Deleted: WAM 103.3(J)(2) …and to notify “the treating provider” by telephone. …of the telephone notification.

However, the longest wait time for a decision is 28 days. A request must be decided within 14 days of the receipt of the request, but that time frame may be extended up to another 14 days if the beneficiary or provider request the extension, or if the extension is needed to obtain additional information and an extension is in the beneficiary’s best interest. A notice of decision will be issued within 28 days of receiving the initial PA request even if all necessary information has not been received.

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1.5.8 Medicaid Payment Decision Review Process (Page 8)

Deleted: Reconsideration

The OVHA will conduct an internal review of the following types of OVHA decisions directly affecting providers in response to requests by providers:

Deleted: for reconsideration

The OVHA will not review any decision other than those listed above.

Deleted: …reconsider its regulations or…

Although this process is not an appeals process, the OVHA’s position that providing a “second look” for certain decisions may help improve accuracy. Any affected provider may ask that the OVHA reconsider its decision. Such a request for reconsideration must be made no later than 21 calendar days after the OVHA gives written notice to the provider of its decision. The reconsideration request should provide a brief


background of the case, and the reasons why the provider believes the OVHA should have found differently. The OVHA will base its reconsideration on the materials submitted by the provider in support of its reconsideration request and any additional information provided by the OVHA. It is expected that the request will contain all supporting documents. Supplemental information submitted after the reconsideration request is made, even if before decision, will not be considered by the OVHA except when the OVHA determines that extraordinary circumstances exist.

Deleted: Believes Presented Sent in

Upon receipt of the request with supporting information, the OVHA will review of the request, and the reasons supporting the provider’s request. The OVHA may consider additional information, either verbal or written, from the provider or others, in order to further clarify the case. The Director of the OVHA, or a designee, will issue a written decision. The OVHA will notify the provider of its reconsideration decision within 30 calendar days of receipt of notice of the request for reconsideration by the provider or notify the provider that an extension is needed. Deleted: …The OVHA will undertake a good-faith …The OVHA will take into consideration…in order to make its best efforts…

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1.9 OUT-OF-STATE PSYCHIATRIC ADMISSION REQUESTS (Page 8)

Beginning August 1, 2009, the OVHA implemented concurrent reviews of all inpatient psychiatric admissions (excluding beneficiaries enrolled in CRT) for Vermont Medicaid primary beneficiaries at out-of-state hospitals. The procedure for CRT admissions remains unchanged. All children and adolescents up to the age of 18 will continue to require a screening by the Local Community Mental Health Center prior to admission. For adults, prior to admission, the referring physician should notify the OVHA Clinical Unit directly at: (802) 879-5903.

All emergent and urgent admissions will require notification to the OVHA within 24 hours or the next business day of admission and all elective admissions will require prior notification prior to admission. Admitting facilities must complete the Vermont Medicaid Admission Notification Form for Out-of-State Hospital Psychiatric Inpatient Services and fax it to the OVHA at (802) 879-5963.

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1.10 IN-STATE PSYCHIATRIC ADMISSION REQUESTS (Page 9) Beginning August 1, 2009, the OVHA implemented concurrent reviews of all in-state psychiatric inpatient admissions for Vermont Medicaid primary children and adolescents, and young adults ages 18 and up to the age of 22 (excluding beneficiaries enrolled in CRT) to the Brattleboro Retreat. All admissions will continue to require a screening by the local Community Mental Health Center prior to admission. The procedure for CRT admissions and concurrent review remains unchanged.

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SECTION 2 PRIOR AUTHORIZATION LISTING (Page 9)

Deleted: …as of July 15, 2004

…are listed in the Fee Schedule posted at: http://ovha.vermont.gov/for-providers. Deleted: www.vtmedicaid.com




OVHA Clinical Unit (802) 879-5903 Dental (802) 879-5903 Deleted: Clinical Reviewer Mail to Dental Health, Department of Health, Burlington

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provider manual summary of updates 9/1/2012 – 6/30/2009

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