DECEMBER 2012
In this issue:
Health System Transformation
Other provider updates
Reminders about CCOB and CCOE coverage
- CCO members who receive both physical and mental health care through their CCO have the Plan Type CCOB listed for their CCO.
- CCO members who only receive mental health care through their CCO have the Plan Type CCOE.
This means that for CCO members with CCOE coding, you need to bill DMAP (not the CCO) for physical health services, including prescriptions and emergency transportation services. For members with CCOB coding, you bill the CCO for both physical and mental health services.
Find more CCO information for providers at www.oregon.gov/oha/OHPB/pages/healthreform/providers/index.aspx.
Bill DMAP (not the CCO) for non-emergent medical transportation
Non-emergent medical transportation services, like 7/11 mental health drugs, are still reimbursed through DMAP, not the physical health plans.
- For non-emergent ambulance services, providers or clients must request prior authorization from the local DHS branch office. The ambulance company will bill DMAP for reimbursement. (Authorization and payment of non-emergent ambulance services in Lane County will be changing in January. Details will be sent out later.)
- For other non-emergent rides, clients should be directed to contact the local transportation brokerage. The brokerage pays the transport provider and submits claims to DMAP. The CCO (not DMAP) pays providers for most services to CCO members.
Upcoming changes to Medicaid PCPCH payment processes
As you may know, on January 1, 2013, the Oregon Health Authority will move from a retrospective to a prospective payment system for supplemental Medicaid payments for Patient-Centered Primary Care Homes. Patient lists will be processed through a new PCPCH panel on the Provider Web Portal at https://www.or-medicaid.gov.
Webinar: Web Portal Orientation
Primary care homes and CCOs are welcome to register for the upcoming Medicaid PCPCH web portal orientation January 3, 2:00 p.m. to 3:30 p.m.
The orientation will provide a foundation of the new web portal functions and an overview of the prospective payment processes. Additional information about the portal launch and a step-by-step user guide will be available prior to January 1.
Medicaid PCPCH Web Portal Orientation
Thursday, January 3, 2013
2:00 p.m. to 3:00 p.m.
Deadlines approaching for providers applying for the 2012 Medicaid Electronic Health Records (EHR) Incentive Program
The Medicaid EHR Incentive program provides federal incentives, up to $63,750 paid over six years, to certain eligible professionals who adopt, implement, upgrade or achieve meaningful use of certified EHR technology. To apply, providers must first register through Centers for Medicare and Medicaid Services (CMS) and then apply using the Provider Web Portal at https://www.or-medicaid.gov to access the online application. A list of the steps to apply can be found on our Web site.
If you are applying for the first time, please don't delay! It may take 6-8 weeks for providers to gain access to the EHR Incentive Program application through the Provider Web Portal.
The deadline for submitting an application is dependent on the provider’s participation year:
- For providers that are participating for their first year, the deadline is March 1, 2013.
- For providers that are participating for a second year payment and are attesting to meaningful use, the deadline is March 31, 2013.
For more information, please visit the Medicaid EHR Incentive Program Web site or contact the Medicaid EHR Incentive Program team at 503-945-5898 with any questions.
Reminders about billing for Vaccines for Children immunizations
For vaccines provided by the Vaccines for Children Program, DMAP only pays for the administration of the vaccine.
- VFC vaccines are provided free to clinics and pharmacies who serve low-income children, including OHP-eligible children, ages 0-18.
- Pharmacists can administer VFC vaccines for OHP-eligible children ages 11-18.
- DMAP will not reimburse providers for privately-funded vaccine serums that are available for free through the VFC program.
For clients with private insurance, bill the Division or the client’s physical health plan (FCHP or CCO) directly for the administration of VFC vaccines. Medicaid is not considered the “payer of last resort” for administration of VFC vaccines.
General vaccine billing reminders
When billing administration for VFC vaccines:
- Bill the appropriate administration procedure code with modifier -26 or -SL for each injection.
- For vaccines administered as part of an Evaluation and Management service (e.g., well-child visit), bill the appropriate administration code with modifier -26, or -SL for each injection in addition to the Evaluation and Management code.
When billing non VFC vaccines:
- Use the appropriate CPT code for the serum, code ranges 90476-90749; and
- Use the appropriate CPT code for the administration, code ranges 90470-90474.
Pharmacies can bill for vaccine administration through Point-of-Sale (POS) using the appropriate National Drug Code (NDC) for the serum and the administration fee shall automatically be applied equivalent to Current Procedural Terminology (CPT) codes 90470-90474. If billing for VFC vaccines, pharmacies must bill on a CMS 1500 claim form for the administration.
New resource for billing physician-administered drugs to DMAP
DMAP has posted a list of the physician-administered drugs that require NDC reporting, with the appropriate unit of measure (UOM) that should be used for each drug. You can find all resources related to NDC reporting to DMAP in our NDC Billing Tips.
Clarifications about billing diabetic infusion supplies
DMAP has received questions regarding coverage and billing of diabetic infusion sets and would like to clarify the policy found in OAR 410-121-0525.
DMAP does not limit diabetic pump infusion sets to one per week. However, DMAP limits the codes that providers may use to bill for these services to HCPCS codes A4221 and K0552. Use these codes to bill for all supplies (including dressings) used in conjunction with a durable infusion pump:
- Use A4221 for all cannulas, needles, dressings and infusion supplies (excluding the insulin reservoir) related to continuous subcutaneous insulin infusion via an external insulin infusion pump, and the infusion sets and dressings related to subcutaneous immune globulin administration.
- Use K0552 for the syringe-type reservoir that is used with the external insulin infusion pump. This is the only infusion supply that must be billed separately from A4221.
The payment amount for code A4221 covers a week’s worth of all necessary diabetic infusion set items and supplies, in whatever quantity the OHP client needs. When you bill DMAP for using code A4221, you are required to furnish a full week’s supplies as the code describes.
Help us improve our provider enrollment process
With recent changes that require more providers to enroll with DMAP as an Oregon Medicaid provider, we are receiving many more requests for enrollment, as well as many more requests that require detailed follow-up. You can help us help you in the following ways:
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Complete all required fields on your provider enrollment request forms, and know what forms you are required to complete. The Provider Enrollment Checklist explains what to submit to DMAP for successful enrollment. Approximately 95 percent of the requests we receive require follow-up for missing information.
- Providers who do not bill DMAP directly, but are required to enroll because they are rendering, prescribing, ordering or referring providers, only need to complete the DMAP 3113.
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Maintain a file of your enrollment requests and the welcome letters that provide your Oregon Medicaid ID. It is the group or individual provider’s responsibility to keep those records. Some group providers will send us spreadsheets of their rendering providers and ask us to provide the Oregon Medicaid IDs and effective dates for each provider, which decreases the time we can spend processing enrollment requests.
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When you need to update information for your Provider ID, send in the DMAP 3035 (Provider Enrollment Update) or submit a request using the Provider Web Portal. Indicate on your cover sheet if you are just adding a group or if you would like everything updated. Approximately 20 percent of the provider enrollment requests we receive are for currently enrolled providers who only require an update sheet.
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Go to the Provider Enrollment Web page for the current enrollment forms and the forms you need to complete for your provider type. Approximately 75 percent of the requests we receive are not processed at first sight, for reasons such as missing pages, forms or supporting documents; and incorrect or outdated forms.
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Out of state providers – Include the claim and your state’s Medicaid Provider ID: In addition to the forms required for all providers who want to bill DMAP, providers more than 75 miles outside the Oregon border must include the claim they want paid for the OHP client they have served, and include their Medicaid Provider ID for the state in which they practice.
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Only submit required information. When you send additional paperwork, it takes us longer to find what we need to process your request.
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Double-check for readability and missing information: If you cannot read what you have written, chances are we can’t either. Check if you have included what you are required to send for your provider type (e.g., IRS letter, Medicare letter, current license, CLIA certificates, surety bonds).
If you have suggestions for how we can improve the resources, instructions or other information available on the Provider Enrollment page, please let us know. If you have suggestions or comments for the Provider Enrollment team, please share.
Provider enrollment questions and answers
What is an ATN? - ATN is the application tracking number. This is used for documenting the enrollment process of enrollment, from beginning to end.
I completed an application on the Web Portal for a provider that just joined our group but it is not found in the system, why? – This happens when you enter the business (group) name instead of the individual provider’s information. Always enter the individual information only. This would include the mail/pay to address information.
OHP training updates: New videos, resources and 2013 Webinar dates
Visit www.oregon.gov/oha/healthplan/pages/tools_prov/training.aspx to find quick links to our 2013 Provider Web Portal prior authorization and billing Webinars, plus new Webinar videos that you can view anytime to review how to verify eligibility, HSC/prioritized list coverage, and the basics of working with OHP.
You can also view a full playlist of all training videos we have available, including the ICD-10 Conference, and training about the upcoming payment process for nursing facility residents who elect hospice care.
DMAP administrative rulebook updates
Administrative rulebooks have been completed for all programs through November 2012.
- All current and past rulebooks are now posted in a new Administrative Rulebooks section on each program's main policy Web page.
- The Rulebook History pages will be deleted later this month. Please refer to the main policy page for your program(s) to find the rulebooks you need.
This change is to prepare for moving these pages to the Oregon.gov Web site sometime next year. If you have comments about this change, or other feedback about the OHP Web site, please let us know.
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