Alaska Medical Assistance Program Hospice Care Provider Billing Manual

172 Pages·2005·5.43 MB·English

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Alaska M edical
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Provider Billing Manual
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Prepared by
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Dear Medical Assistance Provider:
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We are pl0eased to provide Iyou with the enclosed provider billing manual to help you prepare your

Medical Assistance claim forms.
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This billing maUnual has been preIpared by First Health Services Corporation for the State of Alaska. First
Health Services is the fiscal agent for the Alaska Department of Health and Social Services.
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The manual contains basic information on coverage and billing for medical services you provide to
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qualified recipients of our vaIrious medical assistance programs. It is designed to help you: 1) fill out
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health insurance claim forms for your eligible patients, 2) understand what medical services are
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reimbursable, and 3) understand t he policies and procedures of these programs.
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As policies and procedures change,R you will receive the updated information through bulletins and
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replacement pages to this manual. Your manual has been arranged in a loose-leaf format divided by
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sections and numbered so that replacement pages can be Feasily inserted.
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It is important to review and insert the updated inIformation pEromptly to keep a current reference. Claim
forms with outdated information may cause the automated payment system to reject the claim request. It
is extremely important that you and your claims peSrsonnel followR the instructions described in the manual
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for your claims to be processed quickly and efficiently.
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It is our intention to make this manual useful to you, and we welcome any suggestions about the format
that you believe would be helpful. O
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Sincerely, I
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Dwayne B. Peeples C

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Alaska Medical Assistance Program Provider Billing Manual
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NHow To Use This Manual
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Information about how to bill the Alaska Medical Assistance program for reimbursement of services
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rendered to medical assistance recipients is contained in this provider billing manual.
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Provider billing manuals are specific to type of service (for example, there are separate manuals for
AinpatienRt hospital, physician services, pharmacy, chiropractic, etc.). Manual pages are printed on three-

hole paper and mailed to providers in a loose leaf format to make updating easy. The manuals are
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o rganized in tRhree numbered sections to assist you in finding the information you need.
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(cid:131) Section I cEontains specific information about how to bill Medical Assistance for a particular type
6of service.
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(cid:131) S0ection II containsI information about supplemental documents and instructions.

(cid:131) Section III contains Sgeneral Medical Assistance program information.
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(cid:131) Appendices are included at the end of the manual for additional information.
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A Table of Contents is included beginning on page vii of each provider billing manual. Use the Table of
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Contents to help locate inforImation in yNour manual.
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Updated 09/02
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Written Correspondence and ProEvider Training
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The provider billing manuals are meant to be used in conFjunction with other provider communication,
including Remittance Advice (RA) MessageVs, letters and other written correspondence, and information
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delivered at provider training seminars.
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Providers are notified of changes in billing and reimbursement policy in weekly RA Messages. An RA is
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issued weekly to providers with claims activity. The Message Page of the RA will contain important
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provider billing information (including new information,O clarifications and reminders). Revised manual
pages are mailed to providers after the RA Messages are issued.
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Provider training topics, dates and locations are also announced in the RA Messages.
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For information, questions or suggestions about the provider billing manuals, other co rrespondence, or
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provider training, contact First Health Services Corporation or the Divisi on of Health Care Services at
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the phone numbers or addresses listed on pages v and vi.
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Telephone Inquiries
UFirst Health Services Corporation
NQuestions? Please call First Health Services Corporation at [phone] or our in-state toll free
7 number, 1-800-770-5650, about your participation in Alaska Medical Assistance. The First Health

DServices staff has been fully trained to answer most of your questions immediately. The following
A numEbers can help you with other, more specific, questions:
ABillingR Procedures

(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
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Cl1aims & Eligibility Status
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(8:00 6a.m. – 5:00 p.m./Claims) in-state toll free 1-800-770-5650
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(8:00 a.m0. – 5:00 p.m./EligIibility) [phone]

Electronic Data InterchaSnge (EDI)
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in-state toll free 1-800-770-5650
[phone]
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Electronic CommercTe Customer Support (ECCS) Coordinator
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: [phone]

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Eligibility Verification System (EVS)
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(24-hour access) toll free 1-800-884-3223
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Enrollment
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(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
VI E [phone]
Fax
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for Provider Inquiry (PI) [phone] or [phone]
for Prior Authorization (PA) (90T7) 644-8131
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for EDI Attachments [phone] or [phone]
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for Resubmission Turnaround Documents N(907) 644-8122 or [phone]

Prior Authorization (PA) I 7

(8:00 a.m. – 5:00 p.m.) inS-state toll free 1-800-770-5650

A(907) 644-6800
Provider Inquiry/Provider Services C
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(8:00 a.m. – 5:00 p.m.) in-state toll free 1-800-770-5650
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[phone]

Report Fraud, Waste, Abuse, or Misuse of the Medicaid Program by ProvMiders or 1
Recipients
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(24-hour access) toll free 1-800-256-0930
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Internet T
First Health Services Corporation – Alaska http://alaska.fhsc.com
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Updated 04/04
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Addresses
UAdjustment/Voids First Health Services Corporation
P.O. Box 240807
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7 Anchorage, AK 99524-0807

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Appeals: 1st Level First Health Services Corporation
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Appeals
A R P.O. Box 240808
Anchorage, AK 99524-0808
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2nd Level Division of Health Care Services
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6 4501 Business Park Boulevard, Suite 24
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0 I Anchorage, AK 99503-7167

Claims: Hospital, ESRSD, and LTC First Health Services Corporation
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P.O. Box 240729
N O Anchorage, AK 99524-0729
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(IHS) Indian HIealth ServNices P.O. Box 241609
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Anchorage, AK 99524-1609
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Pharmacy RP.O. Box 240649
R Anchorage, AK 99524-0649
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All Others P.O. BFox 240769
VAnchorage, AK 99524-0769
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Electronic Media Claims (EMC)/Electronic SFirst Health SeRrvices Corporation
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Commerce Customer Support (ECCS) EMC Department/ECCS Department
P.O. Box 240808 T
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Anchorage, AK 99524-0808
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Enrollment First Health Ser vices Corporation
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Provider Enrollment

P.O. Box 240808 S

Anchorage, AK 99524-0808 A
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Inquiries and Correspondence First Health Services Corporation
Provider Services Unit O
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P.O. Box 240808
Anchorage, AK 99524-0808 M 1
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Prior Authorization First Health Services Corporation
Prior Authorization Unit L 5

P.O. Box 240808 E -
Anchorage, AK 99524-0808
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SURS (Surveillance and Utilization Review First Health Services Corporation
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Subsystem) Surveillance and Utilization Review
P.O. Box 240808
Anchorage, AK 99524-0808
Updated 04/04
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State of Alaska
Alaska Department of Health and Social Services*
UInternet Web Site: http://www.hss.state.ak.us
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Alaska Medical Assistance/Division of Health Care Services
A IntEernet Web Site: http://www.hss.state.ak.us/dhcs/contacts.htm
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Call: [phone]

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M edicaid PrRovider Fraud Control Unit, Department of Law
To1 report fraud of the Medicaid program by providers
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Call: V(907) 269-6279
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Write: SMedicaid Provider Fraud Control Unit
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Criminal Division
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310 K Street, Suite 300
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AnchorageN, AK 99501
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Fraud Control Unit, DivisiLon of Public A ssistance, Department of Health and Social
Services
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To report recipient Fraud and AbusRe of Medicaid and other public assistance programs
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Call: Toll free: 1-800-4F78-6406
In Anchorage V(907) 269-1060
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In Wasilla [phone]
In Kenai (S907) 283-2947R
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In Fairbanks [phone]
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Write: Fraud Control Unit
State of Alaska, DHSS N O

Division of Public Assistance
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3601 C Street, Suite 200

Anchorage, AK 99503 S

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* For more contact information, see Appendix A.
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Table of Contents
Hospice Care
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7 Introductory Letter.....................................................................................................................iii

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A HoEw To Use This Manual...........................................................................................................iv
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Telephone Inquiries....................................................................................................................v
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Addresses........E...........................................................................................................................vi
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Section I— Hospice Care Policies and Claims Billing Procedures I-1
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Services.....U.............................I................................................................................................................I-1
Table I-1. Hospice Care Services.....................................................................................................I-2
Services ConNsistent with theO Written Plan of Care...........................................................................I-2
Nursing Care.......T..............................................................................................................................I-2
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Medical Social ServicIes.....................:..............................................................................................I-2
Hospice Physician ServLices................... ...........................................................................................I-2
Physical Therapy, Occupat ional Therapy, and Speech Therapy......................................................I-2
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Durable Medical Equipment, Medical Supplies, Biologicals, and Drugs........................................I-3
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Home Health Aide and Homemaker Services.E.................................................................................I-3
Counseling Services....................E.....................................................................................................I-3
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Services in a Nursing Facility or Intermediate Care Facility for the Mentally Retarded.................I-4
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Private Duty Nursing Services..................I....................E...................................................................I-4
EPSDT on File for Recipients Under 21..........................................................................................I-4
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Medicare/Medical Assistance Hospice Election.I........................ .....................................................I-4
Documentation.......................................................................................................................................I-5
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Certification of Terminal Illness............................O...........................................................................I-5
Election Statement................................................................................O............................................I-5
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Written Plan of Care.............................................................. ....................... ....................................I-6
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Prescribed Drugs: Prior Authorizations and Limitations......................................7.................................I-7

Provider Participation Requirements...............................................S......................................................I-7
Recipient Eligibility................................................................................ ......................A.........................I-8
Verification.......................................................................................................................................I-8
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Table I-2. Advantages of EVS.........................................................................................A.................I-8
Eligibility Codes...........................................................................................O....................................I-8
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Table I-3. Eligibility Codes for Hospice Services......................................................................... ...I-8
Reimbursement.........................................................................................................M...........................I-10
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General...........................................................................................................................................I-10
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Pricing Methodology......................................................................................................................I-10
Payment if a Recipient Resides in a Nursing Facility.........................................................L...........I-10 5

Payments to a Hospice for Private Duty Nursing Services.......................................................E.....I-10 -
Payments to a Hospice for Inpatient Care......................................................................................I-11
Physician Services..........................................................................................................................I-T11
Revenue Codes...............................................................................................................................I-12 E
TPL (Third Party Liability).................................................................................................................I-13
Federal TPL Waiver.......................................................................................................................I-13
Recipients with VA, Medicare, and Medicaid................................................................................I-13
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Obtaining a VA Medicaid Denial Letter........................................................................................I-14
Providers Can Attach Other Insurance Benefit Booklet Pages......................................................I-15
Third Party Liability (TPL) Avoidance..........................................................................................I-15
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Claims Billing Procedures...................................................................................................................I-18
N Claims: General Instructions..........................................................................................................I-18
7 Claims: Specific Instructions..........................................................................................................I-18

DRevenue Codes...............................................................................................................................I-18
A EUB-92 Instructions.........................................................................................................................I-18
Medicare/Medical Assistance Crossover Billing.................................................................................I-26
A BRilling Medical Assistance for Services Denied or Limited by Medicare.....................................I-26

Receiving Payment from Medical Assistance................................................................................I-26
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CompleRting the Medicare/Medical Assistance Crossover Billing..................................................I-27
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Secti6on II—Supplemental Documents and Instructions II-1
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Attach0ments to the ClaiIm Form...........................................................................................................II-1

Proof of Timely Filing Documentation..........................................................................................II-1
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ElectronUic Claims AttachmIent Transmittal....................................................................................II-1
Insurance Explanation of Benefits (EOB)......................................................................................II-3
Explanation Nof Medicare BeOnefits/Medicare Remittance Notice (EOMB/MRN) or
Medicare PTayment Report...................................................................................................II-4
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Transportation AuthorizaItion and Invoice: (AK-04)............................................................................II-5
Requesting TransportatLion/Accommoda tion Services...................................................................II-5
Step By Step...................... .............................................................................................................II-6
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Remittance Advice.............................................................................................................................II-10
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Cover Page.......................................................E.............................................................................II-10
Message Page..............................E...........................F......................................................................II-11
Adjudicated Claims (Paid and Denied Claims)............................................................................II-12
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Adjustment Claims....................................I....................E...............................................................II-14
Voided Claims..............................................................................................................................II-17
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In-Process Claims................................................I........................ .................................................II-18
Financial Transactions..................................................................................................................II-19
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EOB Description Page...........................................O.......................................................................II-21
Remittance Summary...........................................................................O........................................II-22
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Resubmission Turnaround Document (RTD)........................ .......................................................II-25
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Adjustment/Void Request Form (AK-05)............................................................7.............................II-30

General Guidelines.....................................................................S..................................................II-30
Adjustment........................................................................................ ......................A.....................II-30
Void..............................................................................................................................................II-30
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Overpayment/Refund......................................................................................................A.............II-31
Completing the Adjustment/Void Request Form (AK-05)..........................O................................II-31
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Claim Inquiry Form (AK-11)............................................................................................................I I-34
General Guidelines...............................................................................................M........................II-34
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Completing the Claim Inquiry Form (AK-11).............................................................................II-34
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Forms Order Request.........................................................................................................................II-36
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Section III—Alaska Medical Assistance Program General Program Information EIII-1 -

Program Introduction..........................................................................................................................IITI-1
Program Background.....................................................................................................................III-1
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Program Objectives.......................................................................................................................III-1
Program Fiscal Agent....................................................................................................................III-1
x Hospice